Barriers to Care Coordination and Medical Home Implementation

PEDIATRICS ◽  
2016 ◽  
Vol 138 (3) ◽  
pp. e20153458-e20153458 ◽  
Author(s):  
M. M. Tschudy ◽  
J. L. Raphael ◽  
U. S. Nehal ◽  
K. G. OConnor ◽  
M. Kowalkowski ◽  
...  
Keyword(s):  
Care Coordination ◽  
Medical Home ◽  
Barriers To Care

On the Threshold to the Adult Medical Home: Care Coordination in Transition

2009 ◽  
Vol 38 (9) ◽  
pp. 513-520 ◽  
Author(s):  
Patience H. White ◽  
Patti Hackett
Keyword(s):  
Home Care ◽  
Care Coordination ◽  
Medical Home

scholarly journals Facilitators and Barriers to Implementing a Patient-Centered Oncology Care Model

2020 ◽  
Vol 16 (12) ◽  
pp. e1441-e1450
Author(s):  
Manasi A. Tirodkar ◽  
Lindsey Roth ◽  
Shelley Fuld Nasso ◽  
Mark W. Friedberg ◽  
Sarah H. Scholle
Keyword(s):  
Care Coordination ◽  
Medical Home ◽  
Financial Incentives ◽  
Technical Assistance ◽  
Patient Centered Care ◽  
Self Report ◽  
Patient Centered ◽  
Leadership Support ◽  
Centered Care

PURPOSE: Oncology practices often serve as the “medical home” for patients but may not have systems to support all aspects of patient-centered care. We piloted a new set of oncology medical home standards that call for accessible, continuous, coordinated, and team-based care. We examined how adoption of the standards varies across a variety of practices and compared practice self-report with external evaluation of implementation. METHODS: Five medical oncology practices in southeastern Pennsylvania implemented the standards from 2014 into 2016. Implementation support included training webinars and technical assistance. External reviewers evaluated practices’ implementation of the standards. We conducted site visits to interview providers and patients. RESULTS: Between baseline and follow-up, practice self-assessments and independent audits showed practices increased implementation of the patient-centered oncology standards. The largest improvement was seen in continuous quality improvement (QI). Practices were less successful in implementing care coordination: achievement on two standards (access and evidence-based decision support) declined from baseline to follow-up. Qualitative analyses revealed that practices focused QI in five areas: goals of care, engaging patients in QI, financial counseling, symptom management, and care coordination. Interviewees talked about facilitators, such as leadership support and physician buy-in, and barriers to transformation, including inadequate resources and staffing. Health information technology both supported and limited implementation. CONCLUSION: Oncology practices showed some progress in their implementation of patient-centered care processes over the course of the pilot program. Systems for tracking and documenting improvement, training for staff and clinicians, leadership support, and alignment of financial incentives are critical to transformation.

A centralized, primary care medical home survivorship model at the GW Cancer Center.

2018 ◽  
Vol 36 (7_suppl) ◽  
pp. 45-45
Author(s):  
Elizabeth Hatcher ◽  
Farzana L. Walcott ◽  
Cam Ha ◽  
April Barbour
Keyword(s):  
Primary Care ◽  
Physical Therapy ◽  
Cancer Survivors ◽  
Weight Management ◽  
Care Coordination ◽  
Medical Home ◽  
Survivorship Care Plan ◽  
Survivorship Care ◽  
The Impact ◽  
Primary Care Medical Home

45 Background: Models for survivorship care are often oncology-based. George Washington (GW) Adult Cancer Survivorship Clinic (ACS) has developed a unique, centralized model for survivorship care delivery staffed by internal medicine providers. The objective is to provide care to survivors that encompass the broad array of chronic issues they face, in addition to guidance on cancer surveillance and prevention. Methods: We implemented a centralized, primary care, consultative model of survivorship care, emphasizing care coordination. A personalized, evidence based survivorship care plan (SCP) is provided to each patient. Patients with complex needs may be seen for follow-up. A copy of the SCP is sent to the patient’s primary care provider (PCP). Referrals are made to our network of specialists within the GW system including: cardiology, neurology, weight management, genetic counseling, dermatology, physical therapy, integrative medicine, psycho-oncology, sexual health, and oncofertility. Referrals are tracked to specialty services using the electronic medical record (EMR). Results: Based on preliminary data, from January 2016 to October 2017, 261 cancer survivors were seen in the survivorship clinic. The majority were breast cancer survivors (166). Referral records were available for 225 patients. Most common were dermatology for baseline skin cancer screening (28%), physical therapy (16%), social work and psycho-oncology (15%), and weight management (15%). Conclusions: Our clinic is based on a primary care medical home model for each survivor, which includes care coordination and referral to specialty services. Limitations include inconsistent referral tracking methods with our EMR and incomplete data for all survivorship patients. Future research plans include assessing the impact of referrals on patient-reported outcomes and morbidity.

scholarly journals Measuring care coordination in German primary care – adaptation and psychometric properties of the Medical Home Care Coordination Survey

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Aleida Ringwald ◽  
Katja Goetz ◽  
Jost Steinhaeuser ◽  
Nina Fleischmann ◽  
Alexandra Schüssler ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Care ◽  
Home Care ◽  
Care Coordination ◽  
Medical Home ◽  
Health Care Team ◽  
Healthcare Team ◽  
Team Members ◽  
Care Practices ◽  
Primary Care Practices

Abstract Background Continuity of care is associated with many benefits for patients and health care systems. Therefore measuring care coordination - the deliberate organization of patient care activities between two or more participants - is especially needed to identify entries for improvement. The aim of this study was the translation and cultural adaptation of the Medical Home Care Coordination Survey (MHCCS) into German, and the examination of the psychometric properties of the resulting German versions of the MHCCS-P (patient version) and MHCCS-H (healthcare team version). Methods We conducted a paper-based, cross-sectional survey in primary care practices in three German federal states (Schleswig-Holstein, Hamburg, Baden-Württemberg) with patients and health care team members from May 2018 to April 2019. Descriptive item analysis, factor analysis, internal consistency and convergent, discriminant and predictive validity of the German instrument versions were calculated by using SPSS 25.0 (Inc., IBM). Results Response rates were 43% (n = 350) for patients and 34% (n = 141) for healthcare team members. In total, 300 patient questionnaires and 140 team member questionnaires could be included into further analysis. Exploratory factor analyses resulted in three domains in the MHCCS-D-P and seven domains in the MHCCS-D-H: “link to community resources”, “communication”, “care transitions”, and additionally “self-management”, “accountability”, “information technology for quality assurance”, and “information technology supporting patient care” for the MHCCS-D-H. The domains showed acceptable and good internal consistency (α = 0.838 to α = 0.936 for the MHCCS-D-P and α = 0.680 to α = 0.819 for the MHCCS-D-H). As 77% of patients (n = 232) and 63% of health care team members denied to have or make written care plans, items regarding the “plan of care” of the original MHCCS have been removed from the MHCCS-D. Conclusions The German versions of the Medical Home Care Coordination Survey for patients and healthcare team members are reliable instruments in measuring the care coordination in German primary care practices. Practicability is high since the total number of items is low (9 for patients and 27 for team members).

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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