This webinar will provide an overview of the development of the Patient-Centered Medical Home and the Case Management Role in the Lahey Health Division of Primary Care. Steps in the current process will be discussed and common issues and barriers to achievement and future plans for case management will be provided to as resources for colleagues dealing with similar issues in their own institutions.
Describe Lahey Health Services Areas
Describe history, timeline, and development of Patient-Centered Medical Home at Lahey
Review Joint Principles for the development of Patient-Centered Medical Home
Describe governance structure created for the initiation and development of Patient-Centered Medical Home
Define the patient stratification criteria for diabetes population management
Review development and outline for Care Coordination orientation
List and discuss the EMR tools developed for patient population management, documentation, and outcome measurement
Define the Care Map for PCMH Case Management
Define the use of chart review and preventive care guidelines in planning for visit
Explain the various evidence-based screening tools used by the case management
Define process for care planning and goal setting with patients
Describe visit stratification and follow-up planning
Identify common engagement issues and barriers to goal achievement
Discuss future plans for case management
Contact hours available until July 17, 2015.
Requirements for Successful Completion: Complete the learning activity in its entirety and complete the online CNE evaluation.
Faculty, Planners and Authors Conflict of Interest Disclosure: Speakers have no disclosures to declare.
Commercial Support and Sponsorship: No commercial support or sponsorship declared.