Change Concepts

• Use planned care according to patient need.
• Use point-of-care reminders based on clinical guidelines.
• Enable planned interactions with patients by making up-to-date information available to providers and the care team at the time of the visit.
  
  

For those interested in the congruence between the Chronic Care Model (CCM) and the PCMH, this change concept is one place where key parts of the CCM are made explicit, especially Delivery System Design and Decision Support.

The goal of this change concept is to make evidence-based care routine. This is accomplished through both planned interactions initiated by the practice, and through point-of-care reminders which help ensure that every interaction is informed by the clinical needs and wishes of the patient.

This means that the availability of up-to-date patient information is key, as is the care team’s ability to review patient data before the visit and communicate via team huddles or other formats to work efficiently as a unit and maximize the value of each interaction.

• Organized, Evidence-Based Care Implementation Guide (April 2011)
  The Change Concept "Organized, Evidence-based Care" is at the heart of the clinical transformation needed to become a PCMH. Over the past 12 years, the CCM has served as a guide to systems who wish to improve their care for the patients who have ongoing health needs including physical illnesses, mental health disorders and behavioral issues such as substance abuse. This implementation guide begins by introducing the CCM and examining the connections between it and the PCMH, and then focuses on critical aspects of the CCM not included in other PCMH change concepts.
    Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations
  
  
• Implementing Effective Clinical Care Management (July 11, 2011)
  Moderator: Nicole Van Borkulo, MEd, Qualis Health
  Speakers: Ed Wagner, MD, MPH, MacColl Institute for Healthcare Innovation, Group Health Research Institute (Seattle, WA); Kathryn Horner, MS, MacColl Institute for Healthcare Innovation, Group Health Research Institute (Seattle, WA); Rebecca Ramsay, BSN, MPH, CareOregon (Portland, OR); Casey Boland, RN, MSN, Multnomah County Health Department (Portland, OR); Jody Reifenberger, MMS, PA-C, East Boston Neighborhood Health Center (Boston, MA)
   Audio & video program   Printable slides
  
  
• Organized, Evidence-based Care (June 7, 2011)
  Moderator: Nicole Van Borkulo, MEd, Qualis Health
  Speakers: Ed Wagner, MD, MPH, MacColl Institute for Healthcare Innovation, Group Health Research Institute (Seattle, WA); Brian Austin, MacColl Institute for Healthcare Innovation, Group Health Research Institute (Seattle, WA); Krista Collins, Central City Concern (Portland, OR); John Holmes, PharmD, Idaho State University Department of Family Medicine (Pocatello, ID)
    Printable slides