Patient Centered Medical Home Summary

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Overview of the Patient Centered Medical Home project piloted by Geisinger Health System in Danville, Pennsylvania Date: October of 2010
Goal: Create value (defined as outcomes relative to input costs), measure innovation returns, and receive market rewards. Requirements: a multidimensional transformation of primary care practice with intensive case management and a payer partnership. Coordinating Primary Care/Team Effort: “patient Centered Medical Home” Geisinger calls it “Personal Health Navigator” aims to help patients manage all the complexities of their care in one setting. Focus on putting patients/families at the center of care. Doctors, nurses, technicians and case managers (who coordinates it all). Constantly monitor patient needs, especially those with chronic conditions) CHF, COPD, Diabetes). Team navigates transitions into/out of hospital/rehab. High risk patients call their case managers cell phone anytime. CHF patients given special scales that electronically transmit daily weights. Time required for Primary Care of patients (traditional model):2 1.Acute Care: 4.6 Hours/day

2.Preventive Care 7.4 Hours/day
3.Chronic Care 10.6 Hours/day
4.Total patient Care: 22.6 Hours /day
Who does what? Physicians focus on Complex medical decisions and nurses focus on process measures (vaccines, educations, DM foot exams, etc). Redesign effort: Geisinger manages twenty-two system wide clinical service lines, each co-led by a physician and administrator pair. Each responsible for achieving their own annual quality and financial budget targets. Geisinger’s model is aligned with the NCQA PPC-PCMH standards. 1 Compensation is for the whole team; try something different… Do not work harder/longer, but smarter! Workflow Redesign: ELIMINATE non-value added work. AUTOMATE work that can be done by a computer or outside an office encounter....
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