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Overview of the PPOC Medical Home Program: The PPOC focuses on providing high quality pediatric care and participating in quality improvement efforts in the member practices. The Medical Home Program supports and leads the practices in transforming the care delivery from reactive episodic care to proactive care. The aim of the PPOC Medical Home focuses on the PPOC Quality Compass which addresses the following: • Manage Population Effectively• Deliver High Reliability/Quality Care • Achieve High Patient Satisfaction• Reduce Total Medical Expense/Costs of Care
The PPOC Medical Home framework consists of three components:
1. NCQA Standards: These are based on the National Committee on Quality Assurance 2008 Patient Centered Medical Home 10 Must Pass Core Elements. These elements include increased access and communication with patients and families, organizing clinical information, identifying important diagnoses and conditions, adopt and implement evidence-based guidelines, test and referral tracking, population management, performance reporting and improvement. Practices are required to examine their current processes and make the necessary changes in their practices to meet these standards. As part of this effort, practices strive to implement processes that can be maintained as well as measure its effectiveness over time.
The PPOC Medical home framework consists of three components:
2. Care Coordination: Practices create a care coordination plan and hire a care coordinator. Care coordination is aimed at improving transfer of patient information and facilitating transitions in care. With care coordination, there is an emphasis on greater teamwork among the practice and following patients care before, during, and after the visit to pediatrician’s office. 3. Family Engagement and Partnership: Many practices are engaging the families in partnership with the clinical staff with the care of the child and in creating stronger medical homes within the practices. The practices are expanding and acting upon opportunities by adding families as a voice in the practice.
American Academy of Pediatrics Preamble to Patient-Centered Medical Home Joint Principles1: • Family Centered Partnership• Community Based System• Transitions• Value (Quality improvement)
(Liaisons [BCH], practice/office managers, practice administrators)
Community Providers
Care Teams: Multiple providers working with
one patientsSchools,
Behavioral/Mental health agencies, Multiservice
agencies
Overall: Improve access to services and resources, and care planning and coordination which will lead to improved quality of care, health outcomes, and increased quality of life of children and youth with multiple medical and psychosocial needs.
Patients/Family: Increase understanding of specialty care, mental health services, educational services, out-of-home care, family support, and other public and private community services that are important for the overall health of the child and family.
Staff: Increase understanding of the elements of medical home and care coordination that impact the practice.
*Process Map Example from Greater Lowell Pediatrics
Standard definition of “Team”A group with a specific task or tasks, the accomplishments of which requires the interdependent and collaborative efforts of its members.
Why? Team structures in the practice setting have been known to…• Reduce physician workload• More time with each patient• See more patients
• Enable standardization of processes across the practice• Foster collaborative office culture• Improve practice-wide communication and understanding of
the underlying goal…buy-in from all• Facilitate and improve preventative and chronic care of
patients• Cultivate practice-wide innovations in patient care• Improve quality and satisfaction
References1 Patient Centered Primary Care Collaborative. (n.d.). Joint Principles of the
Patient-Centered Medical Home. 2 The National Committee for Quality Assurance. (n.d.). Patient-Centered
Medical Home Recognition.3 U.S. Department of Health & Human Services. (n.d.). Defining the PCMH.4 Patient Centered Primary Care Collaborative. (n.d.). Joint Principles of the