Quality and Care Management
Quality improvement and care management are two hallmarks of a Patient Centered Medical Home. Using evidence-based medicine and state-of-the-art chronic care management, the physician-led primary care team delivers excellent care and also coordinates care within the practice and throughout the health care system and community.
Group visits allow physicians to deliver patient education and self-management skills while increasing financial productivity. They also offer patients with similar illnesses an opportunity to interact with and learn from one another
Using paper or electronic chronic disease registries, for example, a practice can track patients who need ongoing care, proactively schedule visits and plan care accordingly. Delivering care according to evidence-based clinical guidelines, a practice can ensure that every patient receives the full scope of necessary care.
Chronic Care Management is one of the most important services provided in a medical home. Working with patients with diabetes, heart disease and other chronic illnesses keeps them as healthy as possible, improves patient outcomes and decreases health care costs.
In a PCMH, a primary care physician coordinates care across all parts of the complex healthcare system (e.g., specialists, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services).
