Patient Centered Medical Home (PCMH)

Interprofessional EducationM. David Stockton, MD, MPHProfessorDepartment of Family MedicineUT Graduate School of MedicineSept. 4, 2013

DefinitionsInterprofessional education(also known as inter-professional education or IPE) refers to occasions when students from two or more professions in health and social care learn together during all or part of theirprofessional trainingwith the object of cultivating collaborative practice[1]for providing client- orpatient-centeredhealth care.

Goals of IPETo meet the globalhealth workforcechallengeTo scale-up and build more flexible health workforcesTo enable local health needs to be met efficiently and effectively while maximizing resourcesAs a means of reducing medical errors and improving the health care system

The Changing Face of Interprofessional Collaboration

Solo PracticeSewanee 1987

Hospital Rounding Teams

Patient Centered Medical Home (PCMH)Team-based health care delivery model including physicians, NPs, PAs, nurses, assistants, staffMay include pharmacist, social workers, psychologist

Future of Family Medicine ProjectSite for patients to receive acute, chronic, and preventive services

Services Should Be:AccessibilityAccountabilityComprehensiveIntegratedPatient-centeredSafeScientifically validSatisfyingPatients and providers

ComponentsPractice OrganizationQuality CarePatient Centered CareHealth Information Technology

Quality CareEstablish performance measuresUpdated problem listIntensive management of high risk patientsMedication reconciliationEvaluate care transition process

Patient-Centered CareSame day appointmentsLinguistically and culturally appropriate servicesCreate care plansConsider home monitoring for chronic conditionsConduct group visits

Health Information Technologies

Proper Infrastructure EHRConnection to medical neighborhoodProactive Health ManagementEvidence based data collection

Practice OrganizationOptimizing Coding and billing proceduresEstablished PCMH leadership teamProvide Staff education and trainingUtilize team based care to meet overall patient needsHealth coach and care coordination functions