Care Coordination

Centralizing Care around the PCMH

WellSpan Health, a community-owned not-for-profit health system and a leader in population health management, knows what it takes to align health care services with the Patient Centered Medical Home (PCMH). WellSpan's leadership has committed to a complete re-design of care team roles, not just in primary care, but throughout the hospital, specialty practices and community-based services. Their innovative model builds on the trusted relationship between patients and their primary care team to ensure high-quality, coordinated care, based on the needs of the patient and family.

Innovations in Comprehensive, Team-based Medication Management

Medications are involved in 80 percent of all treatments and impact every aspect of a patient's life. Drug therapy problems occur every day and represent a public health challenge that add substantial costs to the health care system. In recent years, Minnesota has established exemplary practices that incorporate medication management and has seen improvements in outcomes of care and reduced costs. This webinar provided an overview and a look at lessons learned from Minnesota's experience using comprehensive team-based medication management to delivery efficient and effective care.

Integration of Clinical Pharmacists into the Medical Home: Measuring Clinical Impact

As the Medical Home gains momentum around the country, health care leaders are challenged to identify and measure the individual contributions from professionals on the care team. The Department of Veterans Affairs launched its version of the Medical Home in 2010 and has successfully incorporated the clinical pharmacist into this model. This presentation highlighted some of the strategies the VA used to standardize and enhance the role of the clinical pharmacist and will focus on systems approaches to measure clinical impacts of these key individuals on the quality and cost of care for pati

Medical Home Innovations at the State Level

Medical home implementation and innovation at the state level plays an important role in improving health care quality while reducing costs. Several states are leading the nation in efforts to study and implement integrative primary care, and are showing impressive improvements in cost and quality outcomes. This month's webinar will provided an overview of the innovative work being done in participating Multi-Payer Advanced Primary Care Practices across the country and highlighted recent results from Independence Blue Cross' medical home model in Pennsylvania.

 

State Innovations: Updates from the Minnesota Health Care Home Initiative

A leader in care quality improvement and cost reduction, Minnesota's Health Care Home (HCH) initiative, which includes 322 certified Health Care Homes, has lowered costs for Medicaid enrollees by more than 9% since the program began in 2010. The Director of Minnesota's Health Care Home initiative, joined us to provide an overview of Minnesota's innovative program and the lead evaluator of Minnesota's Health Care Home initiative reviewed key findings of the 2014 Health Care Home Evaluation Report to the Minnesota State Legislature.

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Overcoming Barriers to Collaboration Among Behavioral Health and Primary Care Providers

The Health Insurance Portability and Accountability Act’s (HIPAA) Privacy Rule can present barriers to collaboration between behavioral health and primary care providers. However, many of those barriers are more perceived than real. This month’s National Briefing provided an in-depth look at the obstacles to sharing data between behavioral health and primary care providers. Dayna Matthew, JD, joined us to present an overview of HIPAA barriers and to debunk common misunderstandings about data-sharing under HIPAA. Ms.

Integrating Peer Support into Primary Care

This webinar focused on how peer support can enhance primary care, chronic disease management, behavioral health and more. Peer support links people living with chronic conditions, providing them with emotional, social and practical assistance.  Speakers will highlight evidence demonstrating the positive impact that peer support has on health outcomes, its role in patient engagement, and the benefits and challenges of integrating peer support in primary care settings.

The Results Are In: An Overview of Key Findings from PCPCC's Annual Report

This year the PCPCC Annual Report, supported by the Milbank Memorial Fund, presents a showcase of the year's 20 peer-reviewed and industry-generated PCMH evaluations that indicate the patient-centered medical home's impact on cost, quality, and population health outcomes. During our January National Montly Briefing, PCPCC Annual Report co-authors Marci Nielsen, PhD, MPH and Nwando Olayiwola, MD, MPH led a discussion of the report's key findings and future implications for the medical home movement.

Working with Care Teams After Treatment

The PCPCC, in partnership with the American Cancer Society launched a three part webinar series in December 2013 that focuses on how patient-centered medical home providers and practices can support patient health and caregiver support after a cancer diagnosis, during treatment, and post-treatment. Expert speakers will discuss how to support patients throughout the care experience including initial diagnosis, active treatment and survivorship.

Working with Care Teams During Treatment

The PCPCC, in partnership with the American Cancer Society launched a three part webinar series in December 2013 that focuses on how patient-centered medical home providers and practices can support patient health and caregiver support after a cancer diagnosis, during treatment, and post-treatment. Expert speakers will discuss how to support patients throughout the care experience including initial diagnosis, active treatment and survivorship.

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