DRAFT: Practice Transformation Toolkit

The PCPCC has gathered and organized a collection of information and resources to assist you with transformation into patient centered medical homes.  These pages are organized by processes utilized during practice transformation and contain practical information and tools to help health professionals provide medical homes for their patient popuations.  Although these pages are primarily targeted towards the medical home care team (clinical and non-clinical), many of these resources may also be useful to patient/consumer organizations, communities, and states.

General Documents

Improving Access to Care

Improving Patient/Family/Caregiver Engagement

  • Patient Portals
  • Personal Health Records
  • Setting Up Patient/Family Advisory Committees
  • Patient/Famliy Experience Surveys
  • Providing Culturally Effective Care

Implementing Team Based Care

  • Team Huddles

Implementing Care Coordination

  • Improving Hand-Offs and Transitions Care
  • Medication Management
  • Certification Program/Competencies for Care Coordinators
  • Test/Referral Tracking Resources
  • Improving Hand-Offs & Transitions of Care
  • Medication Management

Improving Practice Workflow

  • Open Access Scheduling
  • Group Visits
  • Utilizing Non-Traditional Visits (e-visits, etc.)

Improving Office Design

  • Utilizing Non-Traditional Visits (e-visits, etc.)

Implementing/Maximizing EHR/HIT

Implementing Population Health & Proactive Primary Care

  • Patient Registries
  • Risk Stratification Tools
  • Reminder/Recall Systems

Implementing Comprehensive Primary Care – Behavioral Health, etc.

Evaluating Your Medical Home and Certification/Recognition

Finding an External Resource to Help

Quality Improvement

Linking Your PCMH to a Larger System (ACOs, etc.)

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