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  • Empanelment | Safety Net Medical Home Initiative
    patients to individual primary care providers PCP and care teams with sensitivity to patient and family preference Empanelment is the basis for population health management and the key to continuity of care The goal of focusing on a population of patients is to ensure that every established patient receives optimal care whether he she regularly comes in for visits or not Accepting responsibility for a finite number of patients instead of the universe of patients seeking care in the practice allows the provider and care team to focus more directly on the needs of each patient Key changes for Empanelment Assign all patients to a provider panel and confirm assignments with providers and patients review and update panel assignments on a regular basis Assess practice supply and demand and balance patient load accordingly Use panel data and registries to proactively contact educate and track patients by disease status risk status self management status community and family need Empanelment Resources Implementation Guides Empanelment Executive Summary Empanelment Establishing Patient Provider Relationships This Implementation Guide offers step by step instructions for assigning and managing panels and strategies for sustaining the effort over time Tools Patient Acuity Rubric Determining the Right Panel Size Addressing

    Original URL path: http://www.safetynetmedicalhome.org/change-concepts/empanelment (2016-04-30)
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  • Continuous & Team-Based Healing Relationships | Safety Net Medical Home Initiative
    patients and provider care team recognize each other as partners in care Ensure that patients are able to see their provider or care team whenever possible Define roles and distribute tasks among care team members to reflect the skills abilities and credentials of team members See examples of one SNMHI participant s interventions and results for this Change Concept Continuous and Team Based Healing Relationships Resources Implementation Guides Continuous and Team Based Healing Relationships Executive Summary Continuous and Team Based Healing Relationships Improving Patient Care Through Teams This Implementation Guide provides guidance on how practices can develop and sustain strong care teams Continuous and Team Based Healing Relationships Supplement Elevating the Role of the Medical Clinical Assistant This supplement provides a curriculum and training materials PowerPoint presentations handouts skill assessments exams etc that practices can use to enhance the skills of MAs CAs In the heading of each section is a Zipped File Icon Click this icon to download a zipped file containing all the resources for that section Tools Team Based Planning Worksheet Types of Call Study Cambridge Health Alliance Model of Team Based Care Implementation Guide and Toolkit Webinars Deeper Dive on Team Roles Part 2 October 25 2012 Moderator Nicole Van Borkulo MEd Qualis Health Speakers Catherine Dower JD Susan Chapman PhD RN and Lisel Blash MS MPA UCSF Center for the Health Professions San Francisco CA Christine Klucznik Cambridge Health Alliance Boston MA Ann Turner and Sarah Deines Virginia Garcia Memorial Health Center Cornelius OR Audio video program Presentation slides Deeper Dive on Team Roles Part 1 October 3 2012 Moderator Diane Altman Dautoff MSW Qualis Health Speakers Ed Wagner MD MPH MacColl Institute for Healthcare Innovation at Group Health Seattle WA Lara Salazar SPHR Montana Primary Care Association Helena MT Sue Barba Ashley Crawford LPN

    Original URL path: http://www.safetynetmedicalhome.org/change-concepts/continuous-team-based-healing-relationships (2016-04-30)
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  • Organized, Evidence-Based Care | Safety Net Medical Home Initiative
    of their entire panel of patients OEBC in a Patient Centered Medical Home PCMH consists of designing each encounter to meet a patient s preventive and chronic illness needs using planned interactions and ensuring appropriate follow up care Evidence based guidelines are embedded into daily clinical practice as well as shared with patients High risk patients are identified to determine they are receiving appropriate care management services Key changes for Organized Evidence Based Care Use planned care according to patient need Identify high risk patients and ensure they are receiving appropriate care and case management services Use point of care reminders based on clinical guidelines Enable planned interactions with patients by making up to date information available to providers and the care team at the time of the visit Organized Evidence Based Care Resources Implementation Guides Organized Evidence Based Care Executive Summary Organized Evidence Based Care Planning Care for Individual Patients and Whole Populations This Implementation Guide begins by introducing the Chronic Care Model and examining the connections between it and the PCMH and then focuses on critical aspects of organized evidence based care including planned care decision support and care management To learn more about providing Organized Evidence Based Care visit these pages on our website Improving Care for Complex Patients The Role of the RN Care Manager Behavioral Health Integration Tools Population Health Patient Care Reminders Step By Step Share the Care Assessment of Team Roles and Task Distribution Workflow Standardization Worksheet Webinars Planned and Mini Group Medical Visits January 10 2013 Moderator Nicole Van Borkulo MEd Qualis Health Speakers Devin Sawyer MD and Jamacca Larman CMA St Peter Family Medicine Residency Program Olympia WA Audio video program Presentation slides Implementing Effective Clinical Care Management July 11 2011 Moderator Nicole Van Borkulo MEd Qualis Health Speakers Ed Wagner

    Original URL path: http://www.safetynetmedicalhome.org/change-concepts/organized-evidence-based-care (2016-04-30)
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  • Patient-Centered Interactions | Safety Net Medical Home Initiative
    culturally appropriate manner in a language and at a level that the patient understands Provide self management support at every visit through goal setting and action planning Obtain feedback from patients families about their healthcare experience and use this information for quality improvement Patient Centered Interactions Resources Implementation Guides Patient Centered Interactions Executive Summary Patient Centered Interactions Engaging Patients in Health and Healthcare This Implementation Guide presents strategies to measure patient experience communicate with diverse patients and actively engage and support patients and their families before during and after office visits Tools Eliciting the Patient s Perspective The Patient Centered Medical Home from the Patient s Perspective Patient Visit Sheet Webinars Using a Patient Centered Care Plan and Teamwork to Support Self Management March 28 2013 Moderator Judith Schaefer MPH MacColl Center for Health Care Innovation at the Group Health Research Institute Speakers Larry Mauksch MEd LMHC University of Washington Department of Family Medicine Seattle WA Berdi Safford MD Family Care Network Bellingham WA Audio video program Presentation slides Tools to Enhance Patient Engagement January 24 2013 Moderator Judith Schaefer MPH MacColl Center for Health Care Innovation at the Group Health Research Institute Speakers Chris Delaney MBA Insignia Health Portland OR Cathy Davenport RN BSN PeaceHealth Eugene OR Shannon Gilbert MHA MultiCare Health System Tacoma WA Jim Weiss MD Primary Health Medical Group Meridian ID Audio video program Presentation slides Humboldt Consumer Engagement Across the Spectrum November 16 2012 Moderator Judith Schaefer MPH MacColl Center for Health Care Innovation at the Group Health Research Institute Speakers Betsy Stapleton FNP and Jessica Osborne Stafsnes Aligning Forces Humboldt at The California Center for Rural Policy Humboldt State University Arcata CA Audio video program Presentation slides Establishing Patient and Family Advisory Councils in the Medical Home October 27 2011 Moderators Nicole Van Borkulo

    Original URL path: http://www.safetynetmedicalhome.org/change-concepts/patient-centered-interactions (2016-04-30)
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  • Enhanced Access | Safety Net Medical Home Initiative
    Care Coordination Change Concepts Enhanced Access Share Print This Page Text Size A A A Enhanced Access Enhancing patient access to care is essential for improving patient outcomes improving patient experience and reducing healthcare costs Enhancing patient access begins with a commitment to eliminating barriers to care including those related to a patient s ability to pay This means providing patients with 24 7 access to their care team during office hours and when the practice is closed providing access to advice through a live coverage system PCMH practices are able to create capacity to care for patients in as close to real time as possible by providing patients with a variety of patient and family centered options that also promote practice efficiency same day appointments telephone email and group visits Key changes for Enhanced Access Promote and expand access by ensuring that established patients have 24 7 continuous access to their care teams via phone email or in person visits Provide scheduling options that are patient and family centered and accessible to all patients Help patients attain and understand health insurance coverage See examples of some of the SNMHI participants Enhanced Access interventions and results Enhanced Access Resources Implementation Guide Enhanced Access Executive Summary Enhanced Access Providing the Care Patients Need When They Need It This Implementation Guide provides strategies and tactics practices can use to enhance patient access by eliminating barriers to care balancing supply and demand and creating capacity to provide care in real time Tools Guide to Appointment Confirmation Calls Secret Shopper Exercise Time to Third Next Available Appointment Sample On Call Guidelines No Show Management Guide Standardized Switchboard Process Map Building Better Care s Open Access Management Implementation Toolkit Webinars Using Technology for Improved Access Secure Messaging April 24 2012 Moderator Donna Daniel PhD Qualis

    Original URL path: http://www.safetynetmedicalhome.org/change-concepts/enhanced-access (2016-04-30)
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  • Care Coordination | Safety Net Medical Home Initiative
    link with them so that information is communicated appropriately consistently and without delay Key changes for Care Coordination Link patients with community resources to facilitate referrals and respond to social service needs Integrate behavioral health and specialty care into care delivery through co location or referral agreements Visit the Behavioral Health Integration page for more information Track and support patients when they obtain services outside the practice Follow up with patients within a few days of an emergency room visit or hospital discharge Communicate test results and care plans to patients families See examples of one SNMHI participant s Care Coordination interventions and results Care Coordination Resources Implementation Guides Care Coordination Executive Summary Care Coordination Reducing Care Fragmentation in Primary Care This Implementation Guide begins with an introduction that defines care coordination and the recommended key changes for safety net practices including a focus on behavioral health integration It is followed by Reducing Care Fragmentation a toolkit that includes a detailed discussion of the four basic elements of effective referral or transition management assuming accountability for care coordination providing patient support developing relationships and agreements with key outside providers and establishing connectivity that ensures appropriate information transfer The toolkit also includes a series of case studies and links to specific tools e g job descriptions and staff training curricula Webinars Closing the Loop with Referral Management February 26 2013 Moderator Ed Wagner MD MPH The MacColl Center for Health Care Innovation Speaker Linda Thomas Hemak MD President and CEO The Wright Center for Graduate Medical Education Presentation slides Redesign of the Hospital Discharge Patient Centered Care to Improve Safety Cost and Outcomes August 14 2012 Moderator Donna Daniel PhD Qualis Health Speaker Kelly McGrath MD Chief Medical Officer Clearwater Valley Hospital and Clinics Idaho Audio video program Presentation slides Care

    Original URL path: http://www.safetynetmedicalhome.org/change-concepts/care-coordination (2016-04-30)
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  • Recognition & Payment | Safety Net Medical Home Initiative
    Medical Home Payment Healthcare Reform Recognition Payment Share Print This Page Text Size A A A Recognition Payment Payers across the country are acknowledging the value of PCMH care by providing PCMH practices with enhanced payment and other incentives Many payers require a practice to become recognized as a medical home in order to be eligible for enhanced payment There are several national and many state based recognition and accreditation

    Original URL path: http://www.safetynetmedicalhome.org/recognition-payment (2016-04-30)
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  • Recognition | Safety Net Medical Home Initiative
    by the Safety Net Medical Home Initiative Publication Change Concepts for Practice Transformation and 2014 NCQA PCMH Recognition Standards A Crosswalk There is a high degree of overlap between the SNMHI Change Concepts for Practice Transformation and NCQA s 2014 PCMH Recognition Standards This crosswalk is intended to help practices understand the commonalities between the SNMHI Change Concepts and the 2014 NCQA Recognition Standards Webinar CMS FQHC Advanced Primary Care

    Original URL path: http://www.safetynetmedicalhome.org/recognition-payment/recognition (2016-04-30)
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