- Overview
- Adult Immunizations
- Alcohol and Substance Use (SBIRT)
- Asthma
- Appropriate Use of Antibiotics for ARI
- Childhood Obesity
- Colorectal Cancer Screening
- Cardiovascular Disease (CVD) and Stroke Prevention
- Depression
- Diabetes in Adult Patients
- Gestational Diabetes
- Hepatitis B and C
- Immunizations
- Motivational Interviewing
- Obesity
- Pediatric Immunizations
- Preconception & Interconception Care
- Prevention
- Tobacco Cessation and Secondhand Smoke Exposure
Providers/Practice Care Teams
The Patient-Centered Medical Home model of care emphasizes whole person orientation with coordinated and/or integrated care, enhanced access and improved quality and safety by promoting prevention, proactively managing chronic illness, engaging patients in their care to attain optimum health, and using electronic systems to support this work. To enable practices to make this transformation and build important infrastructure, the PCMH model realigns payment to include standard fee for service, a monthly care management fee and a bonus for meeting or exceeding quality outcomes. This ‘blended’ payment model shifts the focus of care delivery away from episodic care toward more comprehensive, holistic care and incorporates the characteristics associated with both lower costs and better outcomes. The documents on this page are meant to provide information and resources on how to build a Patient-Centered Medical Home.
Thank you!
We are very grateful to the following organizations for funding the Patient Centered Medical Home Pilot.
Click on a link below to be taken to the corresponding section on this page:
- Webinars
- Access and Scheduling
- Care Management
- Organization of Practice
- Patient-Centered Communication
- Patient Tracking and Population Management
- Planned Care
- Quality and Performance Improvement
- Technology
- General PCMH
- June 12-13, 2009 Shared Learning Collaborative
Webinars
- PCMH Pilot Practice Webinar (October 15, 2010)
- RMD Demonstration on Patient Portal (October 6, 2010)
- Introduction to RMD Usage: A Demonstration (September 20, 2010)
- PCMH Standing Orders and Protocols (September 17, 2010)
- PCMH Overview (September 3, 2010)
- The Five Dysfunctions of a Team - Judy Hewitt (June 18, 2010)
- Lowering Colorado's Blood Pressure - Mori Krantz, MD, FACC (February 5, 2010)
- Orientation to the Care Model - Kathy Reims, MD (June 5, 2009)
- Model for Improvement - Cory Sevin, RN, MSN, NP (May 15, 2009)
Access and Scheduling
Presentations
- Improving Access (Houck)
Workbooks
Educational Materials
- (coming soon)
Articles
- (coming soon)
Care Management
Presentations
- Blood Pressure (Krantz, MD)
- Self-Management Support (Reims)
- Care Coordination (Dave Downs, MD and Marjie Harbrecht, MD)
Educational Materials
Videos
- The Chronic Care Model (Ed Wagner)
- Orientation to the Care Model (Kathy Reims, MD – Recorded Webinar 6/5/09)
Organization of Practice
Presentations
- Practice Transformation (Ed Wagner, MD)
- NCQA (Elizabeth Kraft, MD)
- Practice Change as a Team Sport (Perry Dickinson, MD)
Workbooks
Educational Materials
Videos
Articles
Patient-Centered Communication
Video
- (coming soon)
Presentations
- Patient Centered (Eileen Forlenza)
Workbooks
- AMA Physician Tip Sheet (Self-Management Support)
- Physician Resource Guide to SMS (Self-Management Support)
Educational Materials
- (coming soon)
Articles
Patient Tracking and Population Management
Presentations
- Registry and Performance Reporting (Gottsman and Hammond)
Workbooks
Educational Materials
Websites
Articles
Planned Care
Video
- (coming soon)
Presentations
- Making a House a Home (Harbrecht)
- Patient-Centered Planned Care - Test and Referral Tracking (Harbrecht and Schilz)
Educational Materials
- (coming soon)
Quality & Performance Improvement
Video
- (coming soon)
Presentations
- IHI: Using the Model for Improvement (Cory Sevin, RN, MSN, NP)
Workbooks
Educational Materials
Websites
- (coming soon)
Articles
- (coming soon)
Technology
Presentations
- E-prescribing and PQRI (Flint and Pace)
Educational Materials
- (coming soon)
Websites
Articles
General PCMH
Videos
Presentations
- PCMH (Paul Grundy, MD)
- Technical Assistance (Zula Solomon, MBA)
Educational Materials/Handouts
Websites
- PCMH Pilot Practice Community Forum
- American Academy of Pediatrics National Center of Medical Home Initiatives for Children with Special Needs
- Medical Home for All
Articles
Workbooks
- NCQA PPC-PCMH Recognition Workbook
- Improving Access: Measuring Demand
June 12-13, 2009 Meeting Materials
The IPIP/PCMH Shared Learning Collaborative was held on June 12-13, 2009 at the Sheraton Denver West. The following materials are in PDF format and are organized by the room and date they were presented. Click on a link below to download the material.
City Lights: Friday
- Welcome Vision of PCMH (Marjie Harbrecht, MD)
- Focus on Patient Centeredness (Eileen Forlenza)
- Better Healthcare: The Undervalued Contribution of the Patient (Jessie Gruman, PhD)
- Patient-Centered Planned Care: part 1 (Marjie Harbrecht, MD)
- Patient-Centered Planned Care: part 2
- Patient-Centered Planned Care: Diagram Handout (Marjie Harbrecht, MD)
- Patient-Centered Planned Care: Prioritizing Care Coordination Diagram Handout (Marjie Harbrecht, MD)
- Patient-Centered Planned Care: Care Management Care Coordination
- Enhancing Access to Care (Richard Wright, MD)
- Got Data (Bruce Bagley, MD)
City Lights: Saturday
- Self-Management Support (Kathy Reims, MD)
- Self-Management Support Resource Article
- Team is Essential (Bruce Bagley, MD)
- Introduction to Process Mapping (Zula Solomon, MBA)
- Introduction to Process Mapping Symbols part 2 (Zula Solomon, MBA)
- Work Flow Analysis: Utilizing IT (Jay Krakovitz, MD and Kathy Reims, MD)
- Wrap Up (Marjie Harbrecht, MD)
Genessee: Friday
- Diabetes: LDL (Lone Tree Family Practice)
- Decision Support (Perry Dickinson, MD)
Genessee: Saturday
- Tobacco Query and Counseling
- Healthier Living Colorado (Chris Katzenmeyer and Penny Studebaker)
Green Mountain: Friday
- Organization of Healthcare: Holding the Gains (Kathy Reims, MD)
- Diabetes: Blood Pressure and Eye Exam (Spruce Street Internal Medicine)
Green Mountain: Saturday
- Infrastructure for Quality (Kathy Reims, MD)
- How to do Team Huddles (Scott Hammond, MD)
- How to do Team Huddles: Anatomy of a Huddle handout
- ReachMyDoctor (Marjie Harbrecht, MD and Greg Sharp, MD)
- ReachMyDoctor: Screenshot handouts
- ReachMyDoctor: Enrollment Sheet handout
Lookout Mountain: Friday
- Clinical Information Systems: Data Patterns (Richard Wright, MD)
- Clinical Information Systems: Data Patterns - Worksheet in Wright
- Clinical Information Systems: Data Patterns - Worksheet in Wright 2
- A1c (Family Care Southwest)
- Diabetes: Self-Management Goal Measures (Lakewood Family Medicine)
Lookout Mountain: Saturday
- Delivery System Design (Dave Downs, MD)
- Delivery System Design: Know Your Process handout
- Delivery System Design: Staff Satisfaction Survey handout
- Delivery System Design: Team Effectiveness Exercise handout
- Delivery System Design: Group Visit Starter Kit handout
- Delivery System Design: Agenda Setting Tool Bubble Diagram handout
- Delivery System Design: Prevention Priorities Article handout
Union Square: Friday
- Clinical Information Systems: Registry Functionality (Scott Hammond, MD and Pam Hohnstein, MA)
- Clinical Information Systems: Registry Functionality handout
- Clinical Information Systems: Registry Functionality Diabetes Population Management Monthly Report handout
- Asthma (Moffat Family Clinic)
- Shared Decision Making: Patient Health History Questionnaire handout
Union Square: Saturday
- Cultural Sensitivity (Arthur McFarlane II)
- Patients and Families as Part of the QI Team (Steve Hurd, PhD)
- Patients and Families as Part of the QI Team: Patient Satisfaction handout
- Patients and Families as Part of the QI Team: Medical Survey handout
- Patients and Families as Part of the QI Team: Dental Survey handout
- Patients and Families as Part of the QI Team: In-Depth Patient Satisfaction Survey Guidelines
- Shared Decision Making (Steve Hurd, PhD)
Additional Information
For questions and additional information, please contact Kari Loken at (720) 297-1681.
