Stories from the Frontline: Patient-Centered Medical Home Care Transitions

Monday, March 21, 2016

The Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI) was a three-year multi-payer demonstration designed to promote clinical model transformation in practices across the state and prepare the practices for PCMHI recognition. It was a partnership between MassHealth, the Massachusetts Medicaid program, and UMass Medical School. An analysis of the project at 46 participating practices finds that primary care practice transformation takes time; care transitions, including emergency room and post-discharge follow-up care, require the development of new clinical workflows; and the processes of care are more likely to improve before outcomes are affected. These lessons learned can aid provider organizations nationwide: focus on highest-risk patients, prioritize high-volume hospital systems for information-sharing; streamline documentation of the workflow in the electronic health record; and clearly identify the role and function of each care team member in the new process.

Institute for Healthcare Improvement annual International Summit on Improving Patient Care in the Office Practice & the Community.