Care Coordination

Meeting Patients Where They Are: A Medical Home Model for High-Risk Patients

Offering a variety of perspectives from patients, care team, and facility staff, this webinar will highlight a medical home model from Seasons of Maplewood in Minnesota that provides team-based, relationship-centered, on-site primary care for over 3,000 high-risk patients. The model emphasizes the coordination of care among primary care practices, assisted living, and group home facilities, and their use of an innovative communication portal to enhance workflows, order entry, and open communication.

Easing the Transition: Core Principles and Values for Building Effective Care Teams

An essential element of the primary care medical home is ensuring that providers take a ‘whole-person’ approach to care that meets each patient’s physical and mental health care needs, including prevention, wellness, acute and chronic care. This requires building a team of care providers around a patient that may include physicians, mental health, advanced practice nurses, pharmacists, nutritionists, care coordinators, and social workers.

Patients as Members of the Medical Home Care Team

The PCPCC Patients, Families, and Consumers Stakeholder Center hosted a  webinar featuring Brad Thompson, MA, LPC-S. Brad talks about his experience as the parent of a child with special health care needs, and that experience helped shape a professional role at his child's pediatric primary care practice. Since 2007, Brad has worked with Shari Medford, MD, a pediatrician in Amarillo, Texas, that supports families of children with special healthcare needs in areas beyond health care services to greatly improve the family’s experience. Brad talks about how his work has improved Dr.

Care Coordination and the Patient's Role in Shared Decision Making and Team Communication

 In this webinar, we explore the definition of the care team and care coordination as well as the key elements of care coordination within the PCMH. We will also talk about the patient’s perspective by reviewing Christine Bechtel’s research on patients and the delivery system as a whole – its challenges and potential solutions – including care coordination and the medical home.  

Supporting Care Coordination within the PCMH model

 Discussion of key ingredients of population health and disease management that support the PCMH. This includes Protected Health Information (PHI) tools that can support the medical home as well as information systems for PCMH care coordination.

Medication Management as a Critical Component in Coordinated Care Systems

You are invited to hear Dr. Brian Isetts, professor, pharmacist and Policy Fellow with the CMS Innovation Center share what is happening at CMS in the area of Comprehensive Medication Management as a critical component in coordinated care systems, including a view of the inter-agency collaborations, key priorities and how we can continue to collaborate closely with CMS.  Following the talk there will be a Q and A period.

Practical Approaches to Enhance Communication and Coordinated Care in the PCMH

This Webinar is hosted by the Center for Multi-stakeholder Demonstration and feature Dr Jennifer Lail from Chapel Hill Pediatrics and Adolescents, P.A. Dr Lail will present some of the steps they took on their journey to becoming a patient-centered medical home with special emphasis on how they coordinate care for their patients with special health care needs. Dr Lail will discuss the critical factors related to coordinating care which include Relationships, Ready Access, Registry/Records, Resources (including Care Coordination services) , Reimbursement and Recruitment.

Tips on Choosing a Care Coordinator and Developing a High Functioning Team

The Center for Multi-stakeholder Demonstrations will be hosting a Webinar at 2 p.m. EST on Tuesday, March 1st featuring Judy Hewitt entitled "Tips on Choosing a Care Coordinator". She will be sharing lessons learned from her extensive experience as well as sharing tips on choosing a care coordinator.For the past 5 years Judy Hewitt has been Practice Manager for Belmar Family Medicine. She was hired about 8 months after Belmar Family Medicine opened their doors.

Care Coordination: Expanding the Team to the Healthcare Community

Hear from a practicing Family Medicine Physician Dr. Holly Cleney on their team approach to care coordination within the community. Learn how their focus on patient centered care across delivery systems has supported effective Care Coordination. Learn from the Lantham Medical Groups practical experience and what their next steps are for their continuous journey of Transformation.Dr. Holly Cleney is a practicing physician with Latham Medical Group in Lathem, New York.

Colorado Multi-Payer Medical Home Pilot - A Year in Review

Stakeholders from the Colorado pilot cover the structure of their pilot, milestones, measures, data, and the technical assistance provided to participating practices. A patient speaks about her involvement in the pilot, a practice and hospital will share their work on strengthening communication between the hospital and practice/provider and a practice care coordinator discusses the work being done to improve coordination of care within their medical neighborhood. 


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