Establishing a Primary Care Medical Home

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Presentation transcript:

Establishing a Primary Care Medical Home Dr. Michael Romano and Oscar Perez TTUHSC DSRIP RHP 15 April 19th, 2013

Development of a Primary Care Medical Home Re-Design of the Kenworthy Family Medicine Clinic as a NCQA Patient Centered Medical Home Focuses on patients with Diabetes High prevalence in our region Particular burden in Hispanics Amenable to intervention Links to 2 other DSRIP projects Ocular Care Chronic Disease Management Registry

Agency for Healthcare Research & Quality Comprehensive Patient-Centered Coordinated Accessible Quality and Safety

NCQA Accreditation Access and communication Patient tracking and registry functions Care management Self-Management support Electronic Prescribing Test Tracking Referral Tracking Performance Reporting and Improvement Advanced Electronic Communications

Kenworthy Family Medicine Initiative Well- established Open- access Scheduling 30% Same-day Appointments Organized Patient Population into 3 Teams 3 to 4 Faculty 8 Residents 1 LVN 4 MA’s Staff support for prior authorizations and results management Pharmacy and Dietary Support Advanced practice providers as part of team

Kenworthy Family Medicine Initiative Next Steps Disease Management Registry Software Begin with Diabetes Patient Portal Family Medicine will be first PLFSOM site in go-live. Est. September 2013 Development of e-referral process From FM to Ophthalmology Facilitate and Track Referrals