PCMH SUSTAINABILITY BEST PRACTICES TOOLKIT
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Different from sustainability, but equally important, is the implementation and maintenance of your PCMH transformation. While we specifically focus on creating a sustainable PCMH model in this toolkit, in this section, we present tools and best practices that will advance your sustainability through the active implementation and maintenance of the PCMH model.
Stop 3: PCMH Implementation and Maintenance
What is Involved in Implementation and Maintenance?
Statewide Healthcare Innovation Plan (SHIP) YouTube Channel
This link consists of videos from the Webinars and learning collaborative sessions for the SHIP cohorts.
Top 10 PCMH Best Practices
Video (Time Mark: 35:14): https://youtu.be/UzPhVBc_g5w?t=2114
Scott Dunn, MD, Sandpoint Family Health Center, shares his “Top 10 Suggestions from a Guy Who’s Been Through It [PCMH].”
PCMH Journey Discussion Panel: Stories of Success from the Field (SHIP)
Creating Sustainable Care Management Programs (SHIP)
Strategies for Addressing the Challenges of Patient-Centered Medical Home Implementation: Lessons from Oregon
This article addresses medical home challenges through observations of exemplary PCMHs in Oregon where the Oregon Health Authority supports and recognizes Patient-Centered Primary Care Homes (PCPCH).
The Team-Based Approach
Creating Patient-Centered Team-Based Primary Care
This white paper discusses the framework for integrating team-based care into the primary care setting and offers strategies to support its implementation.
Building the Ideal PCMH Team
This presentation covers teambuilding and the other elements needed for a successful medical home.
Role of Staff and Non-Physician Clinicians in Patient Centered Medical Home
Learn how to better evaluate your employees and define their roles to help the practice achieve and/or maintain PCMH status.
Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit
This toolkit discusses the roles and responsibilities of the care team members in a PCMH.
Implementing Team-Based Care
These tools and resources offer implementation support for your practice. You can download them and modify to fit your needs.
Patient Centered Medical Home: Tips to Maintain Your Recognition
Transforming to the PCMH model is not easy. Here are useful tips to help maintain your status.
Achieving True Transformation
Creating A Medical Home is About Improvement, Not Checking Boxes
Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy, provides a historic look back at the creation of PCMH with a look forward to sustaining the PCMH model.
Patient Centered Medical Homes: Are You Just Checking the Boxes?
This gives insight into the transformation and recognition process for a PCMH. It includes a quick self-assessment to decide if your practice is “just checking the boxes.”
When Enough is Enough: Dealing with Change Fatigue
This presentation by TransforMED discusses the signs and symptoms of change fatigue and some mitigation strategies.
Leadership and Provider Engagement
Leadership Tools to Meet the Adaptive Challenges of PCMH Transformation
This Webinar recording is the story of implementing a practical set of leadership tools robust enough to embrace change and actively involve the entire organization in its own transformation.
Engaged Leadership: Strategies for Guiding PCMH Transformation
The Safety Net Medical Home Initiative’s Implementation Guide gives additional resources for engaging leadership and implementing the PCMH model.
PCMH Coordinator Job Description
This is an example of a job description for a PCMH Coordinator which provides a list of duties, physical requirements, and qualifications for employment.
Job Description Recommendations
This document gives examples of how to include NCQA-specific language into care team members' job descriptions.
Key Steps for Creating Patient and Family Advisory Councils in CPC Practices
This resource outlines the steps for setting up patient and family advisory councils. It lists the roles and responsibilities of the staff members needed to run an advisory council.
Putting the Patient in PCMH
The patient is key to implementing and sustaining a PCMH. Here are some resources to help you keep the patient at the forefront of your efforts.
How Non-Clinical Staff Enable Patient Engagement
This article describes how non-clinical staff (patient navigators, health coaches, community health workers, etc.) are vital staff members of the multidisciplinary care team.
Patient and Family Engagement: A Framework for Understanding the Elements and Developing Interventions and Policies
This article discusses the forms, levels, and factors that influence patient engagement initiatives.
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