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Establishing a Primary Care Medical Home

Establishing a Primary Care Medical Home. Dr. Michael Romano and Oscar Perez TTUHSC DSRIP RHP 15 April 19 th , 2013. Development of a Primary Care Medical Home. Re-Design of the Kenworthy Family Medicine Clinic as a NCQA Patient Centered Medical Home Focuses on patients with Diabetes

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Establishing a Primary Care Medical Home

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  1. Establishing a Primary Care Medical Home Dr. Michael Romano and Oscar PerezTTUHSC DSRIP RHP 15 April 19th, 2013

  2. Development of a Primary Care Medical Home • Re-Design of the Kenworthy Family Medicine Clinic as a NCQA Patient Centered Medical Home • Focuses on patients with Diabetes • High prevalence in our region • Particular burden in Hispanics • Amenable to intervention • Links to 2 other DSRIP projects • Ocular Care • Chronic Disease Management Registry

  3. Agency for Healthcare Research & Quality • Comprehensive • Patient-Centered • Coordinated • Accessible • Quality and Safety

  4. NCQA Accreditation • Access and communication • Patient tracking and registry functions • Care management • Self-Management support • Electronic Prescribing • Test Tracking • Referral Tracking • Performance Reporting and Improvement • Advanced Electronic Communications

  5. Kenworthy Family Medicine Initiative • Well- established Open- access Scheduling • 30% Same-day Appointments • Organized Patient Population into 3 Teams • 3 to 4 Faculty • 8 Residents • 1 LVN • 4 MA’s • Staff support for prior authorizations and results management • Pharmacy and Dietary Support • Advanced practice providers as part of team

  6. Kenworthy Family Medicine Initiative • Next Steps • Disease Management Registry Software • Begin with Diabetes • Patient Portal • Family Medicine will be first PLFSOM site in go-live. Est. September 2013 • Development of e-referral process • From FM to Ophthalmology • Facilitate and Track Referrals

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