Practical Considerations for Clinics Working Toward Achievement of Medical Home Principles

Coordination of Care

• Does every patient in your system have an identified (set of) Personal Physician(s) or Provider(s)? Do even the most complex patients have a continuity care team?  
   
• Does your whole clinic system prioritize opportunities to place patients with continuity providers, with the clinicians who know them best?

  Do personal physicians in your clinic process all incoming information about their patients?
   

• Will this information, and the follow-up recommendations generated by it, be reliably inserted into easily accessible parts of the patient’s chart? Will team partners view it? 

• Are problem lists, medication lists, and care plans reliably updated from clinic visits and from outside provider visits?

• Does your clinic employ well-designed systems for patient contact and follow-up?

• Do you employ team care principles, utilizing specialty nurse educators, dietary services, counselors, social workers, etc?  Do those team members communicate efficiently and promptly with each other?  Is this communication digested by the team leader?
   

• Have you crafted patient registries for specific chronic condition monitoring?

• How does your clinic routinely assure patient education and understanding of diagnoses, recommendations, and next steps?  Can patients access providers with questions?
   

• Have you begun to utilize the Care Coordinator model of care?  Who helps your patients find an interpreter, or a ride to the pharmacy?  Who ascertains transfer of pertinent information from nursing home to hospital to clinic?
   

• Does your clinic have direct and open lines of communication with pharmacy, radiology, emergency care, nursing home, rehabilitative services, consultative specialty, inpatient hospitalization, maternity health, and behavioral health resources?  Who communicates with these other providers about the patient – your questions, their needs, their history/meds/problem list – and to what extent?  Do they communicate back?  Can you communicate in real time?  Is this encouraged?
   
• Can ER docs and hospitalists contact you (or your proxy) in real time to confer about patients?  Can you access them?  Is this done? 
   

• Will consultants return patients to the home clinic for further coordination?  Will they collaborate with you before they augment the service you requested?
   

• Do all physicians serving inpatients in your medical homes write orders independently, or are orders coordinated through an attending physician?
   

• Do you utilize decision-support tools or software to accurately and efficiently order appropriate tests (radiologic, other diagnostic) for patients?
   

• Are you and your partners working within your system and community (The MAFP should help!) to persuade staff at consultative and inpatient facilities to build you meaningfully into the care of your patients in those settings?  In other words, are you pushing to regain/retain whole-system support for being the center of communication and care coordination for patients enrolled in the medical home you have constructed?
   

• Have you joined the compensation reform discussion, toward personal physician payment for care coordination, and care of patients with chronic conditions?  (Join an MAFP Committee!)
   

• Are you succeeding at transforming electronic health records into a useful and efficient tool of coordination – for all sorts of aspects of care – rather than letting it become the object of care or the object of communication itself?
   

• Do your patients receive SEAMLESS Care?