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Evolution of a Patient-Centered Medical Home

Carrie Vaughan, for HealthLeaders Media, February 10, 2011
  • Our COGNOS Project (using business intelligence software to build a data mart and auditing tools) enables us to do real-time auditing on our care processes and outcomes.
  • Believing the key to 21st century healthcare is thinking about our patients when they’re not in our presence and using technology to fulfill the requirements of excellent care.

This process led us to seek medical home recognition from the National Committee for Quality Assurance [NCQA] and accreditation from the Accreditation Association for Ambulatory Healthcare [AAAHC], the two bodies offering evaluation of medical groups as medical homes.

HL: How does your model of care work?

Holly: At the core of SETMA’s practice is that one or two quality metrics will have little impact upon the outcomes of healthcare delivery. SETMA employs two definitions: A “cluster” is seven or more quality metrics for a single condition (i.e., diabetes or hypertension), and a “galaxy” is multiple clusters for the same patient (i.e., diabetes, hypertension, lipids, and CHF). SETMA believes that fulfilling clusters and galaxies of metrics at the point of care will change outcomes. The following are the key elements of our model of care: 

  • The tracking by each provider on each patient of their performance on preventive, screening, and quality standards for acute and chronic care. Tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the provider, nurse, and clerk. 
  • The auditing of performance on the same standards either of the entire practice, each individual clinic, and each provider on a population or panel of patients.
  • The statistical analyzing of the above audit performance to measure improvement by practice, by clinic, or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, socioeconomic groupings, education, and frequency of visit.
  • The public reporting of performance on hundreds of quality measures by provider. This places pressure on all providers to improve, and it allows patients to know what is expected of them. The disease management tool plans and medical home coordination document summarizes a patient’s state of care and encourages them to ask their provider for any preventive care that has not been provided. We believe this is the best way to overcome provider and patient treatment inertia.
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