Retention: Building a Patient-Centered Medical Home in HIV Primary Care through PUFF (Patients Unable to Follow-up Found)

2012 ◽  
Vol 23 (3A) ◽  
pp. 81-95 ◽  
Author(s):  
Amy M. Sitapati ◽  
Jan Limneos ◽  
Militza Bonet-Vázquez ◽  
Moira Mar-Tang ◽  
Huifang Qin ◽  
...  
Keyword(s):  
Primary Care ◽  
Medical Home ◽  
Patient Centered Medical Home ◽  
Patient Centered ◽  
Hiv Primary Care

scholarly journals Evaluation of liver test abnormalities in a patient-centered medical home: do liver test patterns matter?

2018 ◽  
Vol 66 (8) ◽  
pp. 1118-1123 ◽  
Author(s):  
Andrew D Schreiner ◽  
William P Moran ◽  
Jingwen Zhang ◽  
Elizabeth B Kirkland ◽  
Marc E Heincelman ◽  
...  
Keyword(s):  
Primary Care ◽  
Medical Home ◽  
Patient Centered Medical Home ◽  
Patient Centered ◽  
Repeat Testing ◽  
Liver Test ◽  
Clinical Patterns ◽  
Multiple Abnormalities ◽  
Liver Tests

Abnormal liver tests are extremely common in clinical practice, present with varying patterns and degrees of elevation, and can signal liver injury from a variety of causes. Responding to these abnormalities requires complex medical decision-making and merits investigation in primary care. This retrospective study investigates the association of patterns of liver test abnormality with follow-up in primary care. Using administrative data, this study includes patients with abnormal liver tests seen between 2007 and 2016 in a patient-centered medical home. Liver tests examined include serum bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase. Patients entered the cohort on the first liver test elevation. The outcome examined was completion of repeat testing, and the proportions of patients without follow-up were compared by patterns of index abnormality. 9545 patients met the inclusion criteria. Of these, 6155 (64.5%) possessed one liver test abnormality and 3390 (35.5%) possessed multiple abnormalities on index testing. Overall 1119 (11.7%) patients did not have repeat testing performed during the study period. A greater proportion of patients with lone abnormalities lacked repeat testing compared with those patients with multiple abnormalities. Differences in repeat testing appeared when comparing clinical patterns of abnormality, with higher proportions of follow-up in patients with testing suggestive of cholestasis. Over 11% of patients with abnormal liver tests did not undergo repeat testing during the study period. Repeat testing occurred more often in patients with multiple abnormalities and in clinical patterns suggestive of cholestasis. This study highlights a potential opportunity to improve quality of care.

Accountable Care in Transitions (ACTion): A Team-Based Approach to Reducing Hospital Utilization in a Patient-Centered Medical Home

2017 ◽  
Vol 31 (2) ◽  
pp. 175-182 ◽  
Author(s):  
Emily M. Hawes ◽  
Jennifer N. Smith ◽  
Nicole R. Pinelli ◽  
Rayhaan Adams ◽  
Gretchen Tong ◽  
...  
Keyword(s):  
Primary Care ◽  
Medical Home ◽  
Patient Centered Medical Home ◽  
Medical Provider ◽  
Care Needs ◽  
Patient Centered ◽  
Access To Primary Care ◽  
Transition Points ◽  
The Impact

Background: There is limited data describing the role of the patient-centered medical home (PCMH) in successful transitions programs and more information is needed to determine the transition points where pharmacist involvement is most impactful. Methods: A family medicine center developed a multidisciplinary outpatient-based transitions program focused on reducing emergency department (ED) and hospital use in medically complex patients. Key team members were a medical provider, clinical pharmacist practitioner (CPP), and care manager. The objective was to evaluate the impact of the program by comparing utilization before and after the intervention and to identify patient and process characteristic predictors of 30-day rehospitalizations. Results: Of the 268 patients included, the mean time to follow-up appointment attended was 11.6 (11.8) days after discharge. The majority of patients (72%) saw their primary care provider at follow-up. Patients experiencing the multidisciplinary intervention had lower 30-day rehospitalizations at 7, 14, and 30 days postdischarge with significance achieved at 14 and 30 days. Compared to before the intervention, reductions in both ED visits and hospitalizations as well as increases in clinic visits were seen at 1, 3, and 6 months. CPP involvement was associated with lower rehospitalizations (7.7% vs 18.8%; P = .04). Conclusion: A multidisciplinary outpatient-based transitions program embedded in the PCMH increased access to primary care and reduced hospital and ED utilization. Face-to-face CPP involvement significantly lowered rehospitalizations. This program describes a standardized approach to complex care needs with defined roles, a model that may be generalizable and reproduced in other medical homes.

scholarly journals Patient-Centered Medical Home Knowledge and Attitudes of Residents and Faculty: Certification Is Just the First Step

2015 ◽  
Vol 7 (4) ◽  
pp. 580-588 ◽  
Author(s):  
Fadya El Rayess ◽  
Roberta Goldman ◽  
Christopher Furey ◽  
Rabin Chandran ◽  
Arnold R. Goldberg ◽  
...  
Keyword(s):  
Primary Care ◽  
Situated Learning ◽  
Medical Home ◽  
Patient Centered Medical Home ◽  
Patient Centered ◽  
Individual Interviews ◽  
Knowledge And Attitudes ◽  
Positive Attitudes ◽  
Level 3 ◽  
The Impact

ABSTRACT Background The patient-centered medical home (PCMH) is an accepted framework for delivering high-quality primary care, prompting many residencies to transform their practices into PCMHs. Few studies have assessed the impact of these changes on residents' and faculty members' PCMH attitudes, knowledge, and skills. The family medicine program at Brown University achieved Level 3 PCMH accreditation in 2010, with training relying primarily on situated learning through immersion in PCMH practice, supplemented by didactics and a few focused clinical activities. Objective To assess PCMH knowledge and attitudes after Level 3 PCMH accreditation and to identify additional educational needs. Methods We used a qualitative approach, with semistructured, individual interviews with 12 of the program's 13 postgraduate year 3 residents and 17 of 19 core faculty. Questions assessed PCMH knowledge, attitudes, and preparedness for practicing, teaching, and leading within a PCMH. Interviews were analyzed using the immersion/crystallization method. Results Residents and faculty generally had positive attitudes toward PCMH. However, many expressed concerns that they lacked specific PCMH knowledge, and felt inadequately prepared to implement PCMH principles into their future practice or teaching. Some exceptions were faculty and resident leaders who were actively involved in the PCMH transformation. Barriers included lack of time and central roles in PCMH activities. Conclusions Practicing in a certified PCMH training program, with passive PCMH roles and supplemental didactics, appears inadequate in preparing residents and faculty for practice or teaching in a PCMH. Purposeful curricular design and evaluation, with faculty development, may be needed to prepare the future leaders of primary care.

Sign in / Sign up

Export Citation Format

Share Document