Foundation Develops Community-Based HIV Testing and Partnerships With Medical Homes, Leading to More Timely Linkages to Care for Newly Diagnosed Patients
A local foundation developed community-based testing programs and partnerships with medical homes to provide real-time linkages to HIV care to newly diagnosed patients and to support these patients in transitioning to care, nearly doubling the number of patients initiating treatment.
Health Navigators Support Self-Management With Primary Care Patients, Leading to Improved Behaviors and Lower Utilization
Health navigators help primary care patients access medical and community resources, leading to significant improvements in health-related and self-management behaviors and health outcomes and to meaningful declines in emergency department and inpatient utilization.
Community-Based Oncology Practice Redesigns Processes Based on Patient-Centered Medical Home Model To Enhance Access, Improve Quality, and Reduce Costs
A community-based oncology practice's patient-centered medical home model features oncology-specific information technology, a standardized assessment, multidisciplinary care plan, patient navigators, telephone triage line, patient education and engagement, and ongoing performance monitoring, leading to improvements in access, quality, and costs.
Multidisciplinary Team, Real-Time Information, and Incentives Help Medical Homes Improve Mental Health and Patient Experience, Reduce Utilization and Costs
As part of a statewide public-private initiative, the diverse Burlington (Vermont) health service area supports 18 patient-centered medical home practices via a multidisciplinary team, real-time electronic information, and financial incentives, leading to more appropriate care, better health outcomes and patient experiences, and lower utilization and costs.
Solo Practitioner Uses Electronic Medical Record To Redesign Care Processes, Leading to Greater Adherence to Recommended Processes and Improved Outcomes
A solo practitioner leverages various functions within the electronic medical record to redesign care processes, leading to greater adherence to recommended care processes and improved outcomes for patients with diabetes.
Maximizing Health Care for Colorado’s Underserved
This operational handbook for safety-net medical homes describes the experience of Doctors Care, a community-funded, nonprofit organization that helps underserved children, adults, and families receive the medical attention they need.
National Center of Medical Home Initiatives for Children With Special Needs Tools/Resources
This Web site includes a variety of tools for families, youth, providers, insurers, communities, and States working to provide medical homes for children with special needs.
Practice Facilitation Handbook: Training Modules for New Facilitators and Their Trainers
The Practice Facilitation Handbook is designed to assist in the training of new practice facilitators as they begin to develop the knowledge and skills needed to support meaningful improvement in primary care practices.
Systems of Care/Patient-Centered Medical Home Initiative: Primary Care–Specialty Care Compact
The purpose of the compact is to improve care and build and sustain trusted medical neighborhoods through a defined communication protocol.
A Collaborative Partnership: Resources to Help Consumers Thrive in the Medical Home
This guide for health care organizations and stakeholders provides resources to improve consumer participation to help design and inform the needed patient focus of the patient-centered medical home.