1. Path to Practice Transformation

2. Failure is just succeeding at learning what doesn’t work!

3. PCMH Domains of Function

4. 1.0 Patient Provider Partnership/Agreement
STEP 4
STEP 7
STEP 1
Staff rooming the patients can continue the PPA conversation. The provider has a conversation with the patient explaining PCMH and PPA and notes the discussion in the patient's medical record.
1.1
Consider using a telephone message that addresses the PPA and PCMH that can be used to educate patients while on hold and/or post information to your practice’s website.
1.1
Provide outreach mailings and/or s of PCMH concepts and PPA to patients that have not been to the office in the past 12 months.
1.2
STEP 8
Conduct staff meetings (with documentation of minutes) regarding the Patient Centered Medical Home (PCMH) concept and the Patient Provider Agreement (PPA).
1.1
Enter the “Patient Provider Agreement” Information into your patient registry / EMR / practice management system, or develop a paper tracking system .
1.1
STEP 5
STEP 2
STEP 9
Develop written PPA statement for patients and signage in your waiting room and/or patient exam rooms.
1.1
Divide the PPA count by your “ current” patient population to calculate the percentage of patients who have received the PPA .
(Not applicable to specialists)
STEP 10
STEP 3 10
Providers ensure that
patients are aware as
healthcare information
is shared among care
partners as necessary.
The PPA needs to be updated to reflect this or the Notice of Privacy Practice, or HIPAA documents will also meet this intent and must be available documents.
1.9
When patients sign in, provide them with a brief PCMH explanation and a copy of the written PPA.
1.1
Use your Practice Management System, EMR and/or registry to determine your total current patient population (the number of current patients seen in the last months).
STEP 6 4

5. 2.0 Patient Registry STEP 3 STEP 1 STEP 4 STEP 2 STEP 5 NEXT PAGE
Repeat Steps 1 and 2 and expand chronic conditions by adding Asthma 2.10, CAD 2.11, CHF 2.12, Conditions Selected by Practice 2.13, Preventive Services (Not applicable to specialists),
CKD 2.16, Pediatric Obesity and Pediatric ADD/ADHD 2.18, data into patient registry.
STEP 1
All-payer registry is used to manage established patients with initial condition of focus.
2.1
STEP 4
Work with the vendor of the registry/EMR to upload the Practice Management System (name, demographics, gender and DOB), E-Prescribing, and Standard Evidence-Based Guidelines data into the registry.
2.3, 2.8
STEP 2
Select a relevant patient population – diabetes for PCP; not addressed in other capabilities for SCP - to focus on for your registry. Data for relevant population must be in a reportable field and include demographic, DOB, name of physicians (PCP & SCP) and clinical metrics (e.g., labs, radiology results and diagnoses with dates of service).
STEP 5
Registry contains clinical information for a substantial majority defined as 3/4 of condition management services received at other sites that are necessary to manage the patient population. Other sites and services are defined as labs, inpatient admissions, ER, UCC, and pharmaceuticals (with dates and dx when applicable.
2.1
2.2
NEXT PAGE

6. 2.0 Patient Registry (con’t.)
STEP 8
Provider examines the patient and orders or has the needed services performed.
STEP 6
Support workflow by either viewing or printing the patient Care Summary prior to the patient’s arrival for ‘alerts’ or gaps in care that need attention at the visit. The Care Summary includes the patient’s PCP and demographic information.
2.4, 2.5, 2.7, 2.8
STEP 9
Provider/MA updates patient registry with dates of services and results received.
STEP 10
Use outreach reports (Gaps in Care) to generate communications to patients ( , phone, text, regular mail or fax) regarding “Gaps in Care” for services that they are due. Registry includes non established Managed Care Patients (assigned but never seen as a patient).
2.6, 2.7, 2.15 (PCP only)
The registry identifies patients with assigned care managers/coordinators.
2.19
STEP 11
STEP 12
The registry contains advanced patient information that will allow the practice to identify and address disparities in care (e.g., primary/preferred language, race, ethnicity, gender identity, and sexual orientation).
2.20 and 2.21
STEP 7
Provider/MA reviews the Patient Care Summary Alerts to identify which services the patient is due for at point of care.
2.4, 2.7, 4.3 6