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Social and Behavioral Sciences Commons

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Massachusetts

Commonwealth Medicine Publications

Primary Care

Publication Year

Articles 1 - 2 of 2

Full-Text Articles in Social and Behavioral Sciences

Stories From The Frontline: Patient-Centered Medical Home Care Transitions, Anita Morris, Joan Johnston, Sai Cherala, Ruth Aboagye, Pam Senesac, Judith L. Steinberg, Jaime Vallejos Mar 2016

Stories From The Frontline: Patient-Centered Medical Home Care Transitions, Anita Morris, Joan Johnston, Sai Cherala, Ruth Aboagye, Pam Senesac, Judith L. Steinberg, Jaime Vallejos

Commonwealth Medicine Publications

The Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI) was a three-year multi-payer demonstration designed to promote clinical model transformation in practices across the state and prepare the practices for PCMHI recognition. It was a partnership between MassHealth, the Massachusetts Medicaid program, and UMass Medical School. An analysis of the project at 46 participating practices finds that primary care practice transformation takes time; care transitions, including emergency room and post-discharge follow-up care, require the development of new clinical workflows; and the processes of care are more likely to improve before outcomes are affected. These lessons learned can aid provider organizations nationwide ...


Implementing Integrated Clinical Care Management In The Patient-Centered Medical Home, Jeanne Z. Cohen, Christine Johnson, Judith Steinberg, Sai Cherala Mar 2014

Implementing Integrated Clinical Care Management In The Patient-Centered Medical Home, Jeanne Z. Cohen, Christine Johnson, Judith Steinberg, Sai Cherala

Commonwealth Medicine Publications

Clinical Care Management (CCM) of the highest risk, most complex and costly patients is a key element of the Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI), and is a new service for most primary care practices. There is much confusion about the role of the Care Manager (CM), and a lack of awareness of key foundational elements critical to successful implementation of CCM. This poster describes the shared approach to implementation of CCM in the MA PCMHI, use of care management and care coordination clinical quality measures to monitor implementation progress, and shared lessons learned in the implementation process.