Thousands of primary care practices have taken the plunge and become recognized as a Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). Many have found the process of transformation to be a challenging but rewarding experience.
Among the innovations practices employ, there is a strong focus on:
- patient management during transitions of care to decrease readmission;
- scheduled, proactive outreach to high-risk patients; and
- initiatives that support patient self-management of chronic diseases.
To facilitate these “pillars” in the medical home, PCMHs have hired care coordinators to create new workflows that integrate these activities into the team approach. This supports collaboration with already overburdened providers, and encourages medical assistants to contribute in a more valuable way to the patient visit.
I am the director for care coordination at one such practice, Vanguard Medical Group (VMG) of Verona, N.J. We have four care coordinators across three locations, which has helped the practice improve outcomes and maintain the NCQA PCMH recognition it first earned in 2009. We leverage tools such as healthcare communication networks and the practice’s EHR to help the care team — made up of physicians, mid-level providers, medical assistants and a diabetes educator — manage patients with complex needs, design standardized treatment plans across the sites, and encourage patient engagement.
Among other benefits, this process has produced decreased utilization rates. One of our local facilities has a 25 percent lower hospital readmission rate than our local peer practices. As data exchange and care quality requirements like these increase, technology-equipped care coordinators will become more integral to achieving success in PCMH programs.