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SOLUTION – THE PATIENT CENTERED MEDICAL HOME (PC-MH)
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| The Patient Centered Medical Home model is an approach to providing comprehensive primary care that facilitates |
| partnerships between individual patients and their personal physicians. |
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| Key Principles: |
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Use of chronic care model to proactively and effectively manage care
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Primary care relationship with a personal physician
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Physician directed medical practice team
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Whole person orientation of patient
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Care is coordinated and/or integrated across all elements of the health care system
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Quality and safety are hallmarks
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Use of Evidence Based Medicine
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Enhanced access to care
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Use of community resources
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Use of Health Information Technology
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NEQCA PLYMOUTH PROVIDER GROUP ONE YEAR PC-MH PILOT
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| The main goal of this pilot is to refine and improve the model for local care delivery for patients with chronic illnesses by |
| implementing the PC-MH model. The pilot will focus on patients with diabetes; however, all the chronic |
| illnesses of this patient population will be treated using the PC-MH model. |
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| Pilot Goals: |
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Improve quality and increase efficiency of services provided to patients with diabetes
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Demonstrate the effectiveness of medication adherence improvement techniques
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Improve chronic disease medication adherence
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Demonstrate effectiveness and business case of the PC-MH model
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