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Innovations
Capitated Health Center Uses Health Coaches to Manage Chronic Illnesses, Leading to Improved Clinical Outcomes 7/30/2014
Trained, bilingual medical assistants in a capitated health center serve as health coaches to chronically ill (often diabetic) patients of similar ethnic or racial backgrounds, leading to better disease management and clinical outcomes for those with diabetes, very positive feedback from patients and center staff, and low turnover among medical assistants and coaches.
Community- and Practice-Based Teams, Real-Time Information, and Financial Incentives Help Medical Homes Improve Care, Reduce Utilization and Costs 7/30/2014
As part of a statewide, public-private initiative, a largely rural Vermont community supports its six medical patient-centered medical home practices with a multidisciplinary provider team, real-time electronic information, and insurer-funded financial incentives, leading to more appropriate care and services and lower utilization and growth in health care spending.
Formalized, Technology-Enabled Referral Relationships Between Medical Center and Community Clinics Enhance Access and Reduce Inappropriate Emergency Department Visits 7/30/2014
A collaborative program leverages information technology to connect ED patients to a medical home and patients receiving care at FQHCs and county health clinics to specialists, leading to enhanced access to care, fewer ED visits, and significant cost savings.
Low-Overhead Medical Home Leverages Information Technology to Attract Both Providers and Patients in Underserved Rural Areas 7/30/2014
A low-overhead medical home leverages information technology to produce a financially viable, high-quality primary care experience that proves to be attractive to both physicians and patients in an underserved rural area.
Navy Medical Home Clinics, Staffed by Integrated Primary Care Teams and Supported by Web-Based Systems, Improve Screening Rates, Access to Care, and Patient-Provider Communication 7/30/2014
Integrated primary care teams in medical home clinics, supported by a Web-based portal and personal health records, provide proactive, coordinated care, leading to higher screening rates, better access to care, and improved patient–provider communication.
QualityTools
A Family Guide: Integrating Mental Health and Pediatric Primary Care 7/16/2014
This guide for families provides practical information about the integrated care movement and how this approach can improve the quality of care children receive in pediatric primary care settings.
Safety Net Medical Home Initiative: Resources and Tools 7/2/2014
This library of publicly available resources and tools can help safety net providers understand and implement the patient-centered medical home model of care.
Maximizing Health Care for Colorado’s Underserved 2/12/2014
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 12/18/2013
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 11/20/2013
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.

Last updated: July 30, 2014.