• Key Functions of a Medical Home

    Access and Continuity

    The American Academy of Family Physicians defines a medical home as one that is based on the Joint Principles of the Patient-Centered Medical Home (PCMH)(3 page PDF) and the five key functions of the Comprehensive Primary Care Plus (CPC+) initiative.

    Learn more about access and continuity, one of the five key functions of medical homes.

    Continuity of Care

    Continuity of care is the process by which the patient and his or her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high-quality, cost-effective medical care. Continuity can be measured at both the patient and clinician level:

    • Patient-centered continuity is the percent of patients that have visits with his or her empaneled physician.
    • Clinician-centered continuity is the percent of visits a clinician has with his or her empaneled patients.   

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    24/7 Access

    24/7 access encompasses the following:

    • Remote login to electronic health records (EHRs) enables clinicians to access and update patient information from nearly anywhere. Increased, secure access to patient records supports better, more efficient patient care and improved work-life balance for physicians.
    • Access to 24/7 care is defined as providing patients and caregivers with a means to make timely contact with health care professionals in the pratice to address all urgent care needs.

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    Empanelment & Panel Management

    Empanelment is the process of identifying and assigning active patients to clinicians or care teams to establish and maintain patient-clinician relationships. The empanelment process includes identifying the ideal panel per clinician, developing initial patient panels per clinician, refining the panels based on clinician input and ideal panel size, and ongoing panel management. The ideal panel may fluctuate over time due to changes both in the practice’s panel as well as the practice’s staffing model.

    Empanelment is the first step to increasing access to care, improving continuity of care, and implementing care coordination, all of which improve health outcomes and reduce costs. Allowing clinicians to focus on forming meaningful relationships with a specific population of patients ensures that all patients receive optimal care regardless of when their last visit occurred. The process of empaneling patients to a clinician or care team also adds value for all participants involved in care delivery, including the patient.

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    Same-day Appointments

    Same-day scheduling is also referred to as open-access or advanced-access scheduling. By changing how you schedule appointments, you can offer patients the convenience and timely access to physicians that they want, while improving the efficiency of your practice. Same-day scheduling reduces staff time spent managing a large number of open appointments and the productivity costs of last-minute cancelations and no-shows. There are many ways to implement same-day scheduling; your practice will need to consider patient needs and staff resources to decide how best to make the transition.

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    Extended Hours

    Patients look to their primary care physicians to help them decide when and if they should seek medical care. Provide your patients with a means to access care beyond your standard office hours. This may include early mornings, evenings, and weekends. It also includes ensuring that your patients have the ability to reach clinicians within your practice outside of hours if they think they may need to seek face-to-face medical care.

    Telemedicine & Telehealth

    Telemedicine is the practice of medicine using technology to deliver care at a distance. It occurs using a telecommunications infrastructure between a patient (at an originating or spoke site) and a physician or other practitioner licensed to practice medicine (at a distant or hub site).

    Telehealth refers to a broad collection of electronic and telecommunications technologies that support health care delivery and services from distant locations. Telehealth technologies support virtual medical, health, and education services.

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    Secure Messaging

    Offering your patients the opportunity to communicate with your practice via email can improve their satisfaction and reduce the amount of time your staff spends returning missed calls. Assess whether your patients and practice are ready for email communication, then find a secure messaging vendor, develop your email policy, define your email processes and procedures, and implement your new messaging service.

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    Patient Portals

    A patient portal is a secure website that gives patients online access to their health information and provides them with a means to communicate with their health care team. Using a patient portal can have many benefits for your patients and your practice, including less time spent on patient calls, decreased mailing costs, and increased patient engagement.  

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