scholarly journals Community-Based Participatory Research in Action: The Patient-Centered Medical Home and Neighborhood

2020 ◽  
Vol 11 ◽  
pp. 215013272096845
Author(s):  
Arletha Williams-Livingston ◽  
Tabia Henry Akintobi ◽  
Ananya Banerjee
Keyword(s):  
High Risk ◽  
Participatory Research ◽  
Care Coordination ◽  
Medical Home ◽  
Community Based Participatory Research ◽  
Patient Centered Medical Home ◽  
Patient Centered ◽  
Community Based ◽  
High Risk Patients ◽  
Risk Patients

Background: The Morehouse School of Medicine Patient Centered Medical Home and Neighborhood Project was developed to implement a community-based participatory research driven, integrated patient-centered medical home and neighborhood (PCMH) pilot intervention. The purpose of the PCMHN was to develop a care coordination program for underserved, high-risk patients with multiple morbidities served by the Morehouse Healthcare Comprehensive Family Health Clinic. Measures: A community needs assessment, patient surveys and provider interviews were administered. Results: Among a panel of 367 high-risk patients and potential participants, 93 participated in the intervention and 42 patients completed the intervention. The patients self-reported increased utilization of community support, increased satisfaction with health care options, and increased self-care management ability. Conclusion: The results were largely attributable to the efforts of community health workers and targeted community engagement. Lessons learned from implementation and integration of a community-based participatory approach will be used to train clinicians and small practices on how to affect change using a care coordination model for underserved, high-risk patients emphasizing CBPR.

Perceptions of High-Risk Patients and Their Providers on the Patient-Centered Medical Home

2015 ◽  
Vol 38 (2) ◽  
pp. 134-143 ◽  
Author(s):  
Shreya Kangovi ◽  
Katherine Kellom ◽  
Christopher Sha ◽  
Sarah Johnson ◽  
Casey Chanton ◽  
...  
Keyword(s):  
High Risk ◽  
Medical Home ◽  
Patient Centered Medical Home ◽  
Patient Centered ◽  
High Risk Patients ◽  
Risk Patients

A Care Coordination Intervention Improves Symptoms but not Charges in High-Risk Patients with Inflammatory Bowel Disease

2021 ◽  
Author(s):  
Jeffrey A. Berinstein ◽  
Shirley A. Cohen-Mekelburg ◽  
Gillian M. Greenberg ◽  
Daniel Wray ◽  
Sameer K. Berry ◽  
...  
Keyword(s):  
Inflammatory Bowel Disease ◽  
High Risk ◽  
Care Coordination ◽  
Bowel Disease ◽  
High Risk Patients ◽  
Risk Patients ◽  
Inflammatory Bowel

Care Management and Care Coordination Within a Patient-Centered Medical Home

2020 ◽  
Vol 50 (11) ◽  
pp. 565-570
Author(s):  
Bonnie J. Wakefield ◽  
Michelle A. Lampman ◽  
Monica B. Paez ◽  
Greg L. Stewart
Keyword(s):  
Care Coordination ◽  
Medical Home ◽  
Care Management ◽  
Patient Centered Medical Home ◽  
Patient Centered

scholarly journals Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians

2015 ◽  
Vol 13 (3) ◽  
pp. 250-256 ◽  
Author(s):  
S. Morton ◽  
S. C. Shih ◽  
C. H. Winther ◽  
A. Tinoco ◽  
R. S. Kessler ◽  
...  
Keyword(s):  
National Survey ◽  
Care Coordination ◽  
Medical Home ◽  
Patient Centered Medical Home ◽  
Health It ◽  
Patient Centered

The patient-centered medical home as an intervention strategy for diabetes mellitus: A systematic review of the literature

2020 ◽  
Vol 16 ◽  
Author(s):  
Lisa S. McManus ◽  
Karen A. Dominguez-Cancino ◽  
Michele K. Stanek ◽  
Juan. M. LeyvaMoral ◽  
Carola E. Bravo-Tare ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Systematic Review ◽  
Care Coordination ◽  
Medical Home ◽  
Health Care Expenditures ◽  
The United States ◽  
Patient Centered Medical Home ◽  
Patient Centered ◽  
Team Based Care ◽  
The Impact

Background: Poorly managed diabetes mellitus increases health care expenditures and negatively impact health outcomes. There are 34 million people living with diabetes in the United States with a direct annual medical cost of $237 billion. The patient-centered medical home (PCMH) was introduced to transform primary care by offering teambased care that is accessible, coordinated, and comprehensive. Although the PCMH is believed to address multiple gaps in delivering care to people living with chronic diseases, the research has not yet reported clear benefits for managing diabetes. Objective: To review the scientific literature about diabetes mellitus outcomes reported by PCMHs, and understand the impact of team-based care, interdisciplinary communication, and care coordination strategies on the clinical, financial, and health related outcomes. Method: The systematic review was performed according to the Cochrane method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight databases were systematically searched for articles. The Oxford Centre for Evidence-based Medicine levels of evidence and the Critical Appraisal Skills Programme systematic review checklist were used to evaluate the studies. Results: The search resulted in 596 articles, of which 24 met all the inclusion criteria. Care management resulted in more screenings and better preventive care. Pharmacy-led interventions and technology were associated with positive clinical outcomes, decreased utilization, and cost savings. Most studies reported decreased emergency room visits and less inpatient admissions. Conclusion : The quality and strength of the outcomes were largely inconclusive about the overall effectiveness of the PCMH. Defining and comparing concepts across studies was difficult as universal definitions specific to the PCMH were not often applied. More research is needed to unpack the care model of the PCMH to further understand how the individual key components, such as care bundles, contribute to improved outcomes. Further evaluations are needed for team-based care, communication, and care coordination with comparisons to patient, clinical, health, and financial outcomes.

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