NHA CCMA PATIENT CARE COORDINATION AND EDUCATION

Healthcare delivery models that practice team-base patient care

Patient-centered medical home (PCMH) and accountable care organizations (ACO)

Institute for Healthcare Improvement (IHI) Triple Aim

1. Improve experience of care

2. Improve health of populations

3. Reduce costs of healthcare

Affordable Care Act (ACA) goals

1. Expand health insurance coverage

2. Shift focus of healthcare delivery system from treatment to prevention

3. Reduce costs and improve efficiency of healthcare

Patient-centered medical home (PCMH)

Care delivery model philosophy intended to improve the effectiveness of primary care; pt treatment coordinated with a PCP to ensure they receive necessary care when and where they need it

Goal is to have a centralized setting that facilitates partnerships btwn the pt, provider, and family (when appropriate)

Core attributes of the patient-centered medical home (PCMH)

1. Comprehensive care (care for all of the pt's needs, not just medical)

2. Patient-centered care (pt and family are core members)

3. Coordinated care (provider-directed medical practice oversees specialty care, hospitals, home healthcare, community services)

4. Accessible services (tools such as scheduling, hours, communication with providers through web portals)

5. Quality and safety commitments (evidence-based medicine delivered by collecting safety data and responding to pt experiences and satisfaction)

Accountable care organization (ACO)

Association of providers and 3rd-party payers that assumes a defined range of responsibilities for a specific population and is held accountable (financially and through specific quality indicators) for its members' health; made of providers with defined pt population who are accountable for quality and cost of care delivered to pts

Many practices, providers, hospitals, speciality clinics within one organizing entity

Focus is on more than the pts in one practice; relationship with the community and places emphasis on public health issues and outreach programs

When to follow up with a patient

24-28 hours after discharge

Purpose of a discharge summary

Documents information necessary for continuity of care (not just a hospital stay)

Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

Replaces formed Medicare reimbursement schedule with a new pay-for-performance program that focuses on quality, value, and accountability

Performance categories for Medicare reimbursement

1. Quality

2. Cost/resource use

3. Clinical practice improvement activities

4. Advancing care information

Learning styles

Auditory, visual, kinesthetic

Cognitive domain of learning

Mental skills and knowledge

Psychomotor domain of knowledge

Physical skills

Affective domain of learning

Interests, attitudes, motivations