Download Advanced Medical Home Model cases (ACP policy monograph)

practice
element:
Practice
Patient
Dr. X (solo practitioner,
admin and clinical
assistants)
Ms. Jones, 67 y.o. woman
with diabetes
electronic
practice
management
no EMR, contracted eprescribing web program
registry
standard and diagnostically
targeted preventive and
condition-specific
monitoring (medical
examinations & tests) and
interventions; managed by
clinical assistant
intake history
and
evaluation
*** (not mentioned)
Advanced Medical Home Model cases
(ACP policy monograph)
Dr. Y (3 physician and 1 APRN Dr. Z (multi-specialty group
group practice; admin and
practice; admin and clinical
clinical assistants not specified) assistants not specified)
Mr. Smith, 42 y.o. man with
Mrs. Murphy, 85 y.o. woman with
asthma, erratic participation in
type II diabetes, congestive heart
medical care, and 3 ER visits in failure, atrial fibrillation, mild
4 months with last visit 6
dementia, multiple medications
months ago
EMR, practice management
EMR, practice management with
with integrated registry
integrated registry functions,
functions, clinical decision
clinical decision support function,
support function, online
online appointment scheduling and
appointment scheduling,
automated appointment reminders,
referrals, medication refills, and referrals, medication refills, order
Personal Health Record (PHR)
entry, and secure HIE portal
integrated with hospital EMR and
care management system
integrated into EMR
implied integration into EMR
phone intake by clinical
assistant; on-site health
questionnaire at kiosk; initial
interview, initial exams, targeted
health behavior interview,
education, and generic targeted
care plan performed and
provided by clinical assistant;
review of results and intake
general history and physical
completed by physician
***
Lifelong Personal Healthcare
(LPHC) cases
Dr. LP, Psychologist HC (with
care coordinator, admin assistant,
and behavioral health clinicians)
(Same for all three patients)
EHR, integrated registry, clinical
decision support, practice (and
care) management inc. secure
contact and scheduling, eprescribing, referrals, and patient
portal: (PHR, HIE, as available
and relevant)
standard and individually targeted
(diagnostic and health risks)
preventive and condition-specific
monitoring (medical examinations
& tests) & interventions integrated
in EHR; managed by care
coordinator based on physician
and psychologist instructions
intake health screening and
questionnaires (inc. electronic,
with response-directed targeted
follow up questions/measures);
initial data gathering by
physician and psychologist; joint
initial treatment planning by
physician and psychologist with
patient and, if relevant, family
practice
element:
scheduling
compliance/
follow
through
appointments and
tests/procedures scheduled
by clinical assistant (based
on physician guidance)
reminders to patient (and
physician?) provided by
clinical assistant
Advanced Medical Home Model cases
(ACP policy monograph)
initiated by patient, clinical
managed and tracked by EMR
monitoring/registry function, or
physician with timely reminders
physician instructs assistant to
review of missed appointments by
remind patient based on care
assistant for commonality and
needs or results from monitoring potential implications, informs
physician; EMR system (and
remote monitoring system)
monitors and reports compliance
test results
completion and results of
tests tracked by clinical
assistant, patient notification
re: results by clinical
assistant per physician
instructions
available electronically to
physician and patient (PHR)
available electronically to
physician and identified care team
members, inc. clinical assistant
selfmanagement
patient completion and use
supervised and assisted by
clinical assistant
physician and patient jointly
determine how to use health
maintenance reminders in PHR;
self-management checklist and
self-evaluation prescribed by
physician for patient completion
self-management tracking and
support provided by collaborating
providers (inc. home health
providers) and technology, as
determined by physician
Lifelong Personal Healthcare
(LPHC) cases
advanced access (combined
planned, open access, and
provider or care team generated
visits and tests/procedures)
care coordinator reminds and
assists patient and monitors
compliance with EHR support,
informs providers to determine
plan; psychologist intervenes to
address clinical barriers to
compliance
care coordinator monitors
completion and availability for
provider visits; physician or
psychologist determines (or
offers) appropriate patient
notification, with care
coordinator administrative
support
physician and psychologist
jointly determine selfmanagement goals, barriers,
and required support; care
coordinator provides and
coordinates relevant logistical
(and technological) support;
psychologist provides clinical
support (e.g., motivational
enhancement, brief
interventions)
practice
element:
medical
decisions
Advanced Medical Home Model cases
(ACP policy monograph)
ordering of tests, review of
targeted and individualized
physician reviews care actions and
results, and required medical action plan, customized
management of other providers,
examinations performed by
educational material from EMR, manages all medical care and
physician
prescription of self-monitoring
health status
and self-care determined by
physician; clinical decision
support function in EMR alerts
physician re: recent relevant
scientific findings
medical
teaching
self-care and compliance
teaching provided by
physician
education re: PHR provided by
physician, and joint decision
made with patient on its use
patientprovider
relationships
engagement, trusting
personal relationship,
support provided by
physician
engagement, trusting personal
relationship, support provided
by physician
referrals
referrals to other providers
ordered by physician,
including to in-office
providers (scheduled &
tracked by clinical assistant)
referrals to other providers
ordered by physicians;
electronic two-way exchange of
relevant information
clinical care
management
***
nurse care management
contracted from outside firm
Lifelong Personal Healthcare
(LPHC) cases
physician has primary
responsibility for the medical
perspective on patients’ health and
provides medical treatment and
referrals; psychologist has
primary responsibility for the
behavioral perspective on
patients’ health and provides
brief behavioral interventions,
behavioral care management,
and referrals
physician identifies teaching
physician and psychologist
needs, relevant provider (inc. home provide targeted health education
health providers) offer teaching as and promotion with administrative
appropriate
support from care coordinator and
targeted materials available
through EHR
engagement, trusting personal
physician, psychologist, and care
relationship, support provided by
coordinator each has trusting,
physician but also by identified
supportive relationships of
care team members involved by
central importance with patients
physician determination
that support engagement and
activation
referrals to other providers ordered referrals to other providers
by physicians electronically and by ordered by physician or
phone; exchange of information
psychologist with consultation
via HIE (and other technology as
from team (managed and tracked
relevant), inc. built in alerts
by care coordinator)
designed by physician based on
provided by psychologist as
identified medical needs, with
integral part of ongoing care
direction to relevant providers (inc.
home health providers)
practice
element:
enhanced
access
(media)
open access
(hours)
enhanced
technological
tools
pharmacy
coordination
mental health
and substance
abuse
treatment
telephone contact with
physician available at
physician’s initiation
***
***
***
***
implied:
external referrals are made
as need is identified
Advanced Medical Home Model cases
(ACP policy monograph)
e-mail access for questions,
phone outreach by physician and
concerns, and routine
other care team members as
communications; phone access
relevant; affiliated home health
prn
agency available for outreach as
prescribed by physician
Open access (same day visits for Managed access based on
calls before 1), 2 week
physician determination,
maximum advance booking
collaboration with affiliated
providers; affiliated after-hours
clinic with information integrated
into practice EMR
remote monitoring (and
e-mail among affiliated providers,
integration with EMR) available electronic consultation available
(inc. video phone link to patient
home via home health providers);
remote monitoring (and integration
with EMR) available through
contract with monitoring agency;
vocal reminders for patient and
alerts for physician available
through remote monitoring service
medications and related expected
***
examinations monitored by
pharmacist who informs physician
of relevant information, concerns
***
implied:
external referrals are made as
need is identified
***
implied:
referrals are made externally or to
co-located behavioral health
providers as need is identified
Lifelong Personal Healthcare
(LPHC) cases
phone, secure e-mail, and
automated or PHR communication
available as relevant and
appropriately used
advanced access and affiliated
after hours services available
practice-specific; immediate,
routine, and consultative
electronic communication
available (whether e-mail, text or
instant messaging, video links,
etc.)
pharmacy links support real-time
and prn monitoring, feedback, and
consultation with pharmacists
psychologist and behavioral
health clinicians are integrated
into care team; mental health
and substance abuse treatment
are integrated with overall
health care
practice
element:
patient
engagement
and activation
proactive care
Advanced Medical Home Model cases
(ACP policy monograph)
***
implied:
patient engagement and
activation is supported by
physician, clinical assistant,
and office staff
***
implied:
patient engagement and
activation is supported by
physician, clinical assistant, and
office staff
***
implied:
patient engagement and activation
is supported by physician, clinical
assistant, and office staff
clinical assistant tracks
participation and results of
care as directed by
physician, who identifies
need for additional
interventions
active monitoring and support as
identified in each patient’s
individualized care plan,
determined by the physician and
patient together
active monitoring and support as
identified in each patient’s
individualized care plan,
determined by the physician and
patient together and actively
managed by the physician
Lifelong Personal Healthcare
(LPHC) cases
patient engagement and
activation are considered results
of clinical care management and
are supported by psychologist’s
ongoing assessment and
intervention as well as
relationship with physician and
with each care team member
the care team, including the
physician, psychologist, care
coordinator, and patient jointly
share responsibility for
proactive efforts on health
promotion, prevention, early
identification and intervention,
and management of all health
and behavioral health problems,
inc. chronic conditions