Module 10 - Patient Care Coordination & Education

patient-centered medical home (PCMH)

• coordinates patient treatment through the primary care provider to ensure the patient receives the necessary care as they need it.

• a centralized setting that facilitates partnerships between the patient, provider, patient family, improving patient outcomes and reducing costs.

accountable care organization (ACO)

group of healthcare providers who collaboratively manage patient care and costs, including multiple practices, providers, and hospital within one organization.

PCMH core function and attributes

• comprehensive care _{^{(care for all of the patient’s needs)}}

• patient-centered care _{^{(patients/family at core of the team)}}

• coordinated care _{^{(medical practice oversees all specialty services, hospital, home health, and community services)}}

• asessible services _{^{(patient information portals: scheduling, provider communication)}}

• quality and safety commitments _{^{(evidence-based repsonsive to patient satisfaction)}}

blood pressure screening

risk factors include African American race, being overweight, family history, and previously recorded higher than normal blood pressure.

mammogram

x-ray of the breast to identify cancer, recommended to start screening at age 40.

pap test

small brush swab that collects cervical cells to identify cervical cancer. recommended every 3 years for ages 21 to 29 and 3-5 years for combination pap + HPV test.

fecal occult blood test (FOBT)

screening for colorectal cancer starting at age 45, collection of stool samples over a few days to detect blood in the stool, if positive a colonoscopy is recommended.

lung LDCT (low-dose computer tomography)

annual screening for lung cancer for adults age 50 to 80 with a 20-pack-year smoking hx who currently smoke or quit within the past 15 years.

DEXA scan

x-ray recommended for women over age 65 and postmenopausal patients under 65 at risk for osteoporosis. tested to prevent osteoporotic fractures and dx osteoporosis.

blood glucose tests

blood test to dx diabetes and monitor glucose, recommended every 3 years for adults, or more frequently depending on medical hx.

dilated eye examination

eye exam that checks for diseases such as glaucoma and diabetic retinopathy. recommend every 1-2 years for adults over age 40, depending on risk factors such as diabetes and family hx.

abdominal aortic aneurysm (AAA)

recommend one-time ultrasonography screening for abdominal aortic aneurysm (AAA) within male patients aged 65 to 75 years who have ever smoked.

hepatitis C screening

person who has risk factors should be tested. risk factors include being born 1945-1965; hx of blood transfusions or organ transplant before 1992; use of injected illegal drugs; and chronic liver disease, HIV, or AIDS.

human immunodeficiency virus (HIV) screening

clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. younger adolescents and older adults at increased risk of infection should also be screened.