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Published byDulcie Powell Modified over 6 years ago
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Elliot Family Medicine at Bedford Commons Patient Centered Medical Home
Citizen’s Health Initiative Presentation March 24, 2010 Amy Dobson Director, EPN
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Presentation Overview
Care Team Development Addition of services within the Medical Home Patient Engagement
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Care Team Development Morning Huddle
Changing staff roles required redesign of clinical staff roles Perception of inability to take on expanded role with constant busy practice
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Clinical Staff Needs Move from task oriented practice to patient oriented practice Staff Engagement Job ownership Professionalism Regular weekly meetings
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Nurse Role Development
Phone Triage Nurse Visits Patient Centered Nurse team member Assessment of complex patients After visit education
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Nurse Health Coach Role
Chronic condition support Follow up with hospitalized patients and patients discharged from the ED/UCC Support to our high needs patients
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Behavioral Health on-site 08/09
Current Data: Rapid referral process Shorter intervention time Improved outcomes
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Pharmacy on-site 08/09 Current Data: 30+ Coumadin Patients
9 Patients for medication management or Bp management
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Patient Engagement Targeted Patient Survey Initiated February 2010
Patient Advisory Board Initiated March 24, 2010
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Questions
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