CCRMC and HC's, Patient Centered Health Home

If they don't load, please find Friday's slides here.
Presented by this weeks improvement event team, here is the future vision of the Contra Costa Regional Medical Center and Health Centers, Patient Centered Health Home (PCHH).

I was happy to see the migration from the term "medical" to the term "health." This is an example of the critical thinking that went into this vision and the push to move toward a model that goes beyond care only and focuses on health.

The team drew from the The National Committee for Quality Assurance's (NCQA), Patient-Centered Medical Home (PCMH) guidelines as a foundation for design. The NCQA describes the PCMH as,

"a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner."

In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time.The NCQA PCMH 2011 program’s six standards are:
• Enhance Access and Continuity
• Identify and Manage Patient Populations
• Plan and Manage Care
• Provide Self-Care and Community Support
• Track and Coordinate Care
• Measure and Improve Performance

The team arrayed some (not all) of CCHS and community services as they relate to each of these standards. The key will be developing and maintaining meaningful connections
As we pursue seamless transitions through the health and health care experience we will become increasingly reliant on the ability to move information reliably. Below is the vision of standard movement of information.
I chose to present drawings rather than the electronic version of the forms here. I have received feedback by some that the forms can feel a bit off putting and intimidating. I am testing use of multiple forms of communication. For those who are counting on seeing the A3, you can find it and the entire presentation on Picasa here.

Exciting times are ahead of us. The first rapid improvement event for the PCHH is in just two weeks!

More, very soon.
Anna