Patient-centered Medical Home/Team-based Care

• Patient-centered Medical Home/Team-based Care

In this course, you have explored critical office-based and clinical patient-based processes and supporting functions that a value-based practice must manage collectively in the drive towards improved patient outcomes.

In managing the health of people, the 7 targeted office-based processes you explored include:

• Patient-centered Medical Home/Team-based Care
• Preventive and Screening Services
• Annual Wellness Visits
• Managing Acute Needs via an Open Access Model
• Quality of Care Metrics/HEDIS®
• Coding to Support Enhanced Coordination
• Staffing

And, the office-based and clinical patient-based supporting functions include:

• Medical Management: Utilization, Case, Data and Pharmacy
• ·Registries, Analytics, and Technology
• Guidelines, Types of Evidence, and Recommendations
• Coordination around SDOH/Community Resources

An expectation of this course or certificate program is not for you to emerge as an expert in all of these processes—remember, it does take a team to manage them. However, it is important that you develop an understanding, beyond basic definitions, of their importance for improving patient outcomes and experience. In addition, it is important to collectively think about these processes in the context of a value-based care model.