Module 4: Patient Care Coordination and Education Flashcards
Two common health care delivery models that practice team-based patient care
- patient-centered medical home (PCMH)
- accountable care organization (ACO)
In both models, the patient is the focus, with all members of the team working to provide the best outcome for the patient using the holistic health care approach.
Team-Based Patient Care
Creates a partnership between providers and patients to ensure that patients are educated and actively involved in their care.
Every team member is accountable for providing quality care with the shared goal of patients receiving the right care from the right person at the right time.
This approach requires communication among all members of the team.
Patient-Centered Medical Home (PCMH)
Care delivery model coordinates patient treatment through the primary care provider to ensure the patient receives the necessary care as they need it.
The goal of a PCMH is to have a centralized setting that facilitates partnerships between the patient, provider, and patient’s family (when appropriate).
The long-term goal of PCMH is to improve patient outcomes and reduce costs.
Advantages:
- improve the patient experience through focused care and increased patient participation related to issues concerning their health care.
- save money by reducing emergency department visits, hospital admissions, and readmissions and thus provide an overall improvement in patient health.
PCMH Core Function and Attributes
- Comprehensive care is an approach that includes care for the patient’s needs—that is, the whole patient and not just certain medical and physical concerns. This involves the providers as well as the entire health care team.
- Patient-centered care positions patients and their families as core members of the team. The focus is on the individual needs and preferences of the patient throughout various stages of life.
- Coordinated care means the provider-directed medical practice oversees all specialty care, hospital, home health care, and community services. The PCMH works to create and maintain open communication between the patient and other members of the team. This is aided by information technology, such as electronic health records (EHRs).
- Accessible services include tools (open scheduling, extended hours, communication with providers) provided through patient information web portals.
- Quality and safety commitments include delivering quality health care. This is met by delivering evidence-based medicine assessed by collecting safety data and measuring and responding to patient experiences and satisfaction.
Comprehensive care
Care designed for the patient’s physical and mental health needs using a team-based approach.
Accountable care organizations (ACOs)
Group of medical professionals associated with a defined patient population that are accountable for the quality and cost of care delivered to those patients. They are at the delivery system level in response to payment reforms instigated by the Affordable Care Act.
Focus is on care coordination but with many practices within one organization. This includes multiple providers, hospitals, and specialty clinics.
- ACOs can also have ambulatory, inpatient, or emergency care services.
Because the focus of care extends beyond the patients in medical practice, there is a relationship to the community in which the organization is located and an emphasis on public health issues to prevent illness.
- The ACO might have outreach programs (smoking cessation, weight loss, nutrition, online education) available to the public to promote wellness.
Primary Care Provider (PCP)
The first provider from whom a patient will seek care and services.
One of the PCP’s main goals is coordinating preventive health care services (regular check-ups, screening, tests, immunizations, health coaching).
PCPs can be family practitioners, internal medicine physicians, medical doctors (MDs), doctors of osteopathy (DOs), or pediatricians.
- Pediatricians offer preventive care services and treat common pediatric conditions such as viral infections or minor injuries from birth through age 18 or 21.
Specialist
A specialist is a provider that diagnoses and treats conditions that require a specific area of expertise and knowledge.
Primary care providers may refer patients to specialists to diagnose or treat a specific short-term condition.
Patients may work with specialists for an ongoing period for chronic diseases.
Examples: dermatologists, oncologists, cardiologists, or gynecologists.
Physician Assistant / Physician Associate (PA)
Physician assistants (PAs) have similar training to physicians and are licensed to practice medicine as long as a licensed doctor (MD, DO) supervises them.
PAs can conduct physical exams, provide preventive care, prescribe diagnostic tests, assist with surgical procedures, diagnose illnesses, and prescribe medicine.
Advance Practice Nurse (APN)
Advanced practice nurses (APNs) have more education and experience than RNs and can usually perform many of the same tasks as a physician assistant.
Ex: Clinical nurse specialists, nurse anesthetists, nurse practitioners (NPs), and nurse midwives
Registered nurses (RNs)
Registered nurses (RNs) are licensed by individual states and have an associate or bachelor’s degree in nursing.
RNs can perform more complicated clinical tasks and usually oversee the case management of patients who have complex chronic conditions.
Licensed practical nurses (LPNs)
sometimes referred to as vocational nurses—are licensed by individual states.
LPNs usually train for approximately 1 year at a community college or vocational school, receiving a diploma or associate degree.
These health care professionals often triage phone calls, administer medications, and assist with other clinical duties in the clinical setting.
Pharmacists
Prepare and dispense medications prescribed by authorized providers.
They must be knowledgeable of individual and various combinations of medicines to educate patients on their use and answer questions about side effects.
Dentists
Diagnose and treat issues relating to the teeth and mouth.
Dentists also educate patients on ways to prevent problems associated with oral health.
Many community health centers include oral health services to patients that are free or on a sliding scale based on patient income.
Occupational therapists
Assist and educate patients on performing everyday tasks after a physical, mental, or developmental disability or injury.
Physical therapists
Assess a patient’s pain, strength, and mobility and then develop a treatment plan to improve movement and pain management.
They are trained to use hands-on therapy, exercises, electrical stimulation, ultrasound, and other techniques to help improve patient movement.
Speech therapists/Speech-language pathologists
Work with patients who have problems with speech and swallowing due to an injury, cancer, or stroke.
They focus on helping a person work toward improving, regaining, and maintaining the ability to communicate, chew, and swallow.
They also assess and treat patients who have speech, language, voice, and fluency disorders.
Psychiatrists
Physicians who diagnose, prescribe medications for, and treat mental, behavioral, and emotional disorders.
Psychologists
Not physicians but have a Doctor of Psychology (PsyD) or a Doctor of Philosophy (PhD) degree.
They work with patients experiencing mental health challenges, such as bipolar and personality disorders.
Social workers
Assist patients and families in times of transition or crisis. They assist patients in a clinical or hospital setting with physical, emotional, and financial issues related to an illness or injury.
Social workers often coordinate additional services (transportation, housing, access to meals, financial resources, long-term care, hospice services).
Providers on the mental health team that work in the PCMH or ACO usually contract with the facility to work a specific number of hours per week. Clinics with a large census can include a full-time social worker as part of their permanent staff.
Registered dietitian nutritionist (RDN)
An expert in diet and nutrition.
RDNs educate patients on the connection between chronic disease and nutrition, assist with menu planning, and help low-income patients obtain healthier foods at lower prices.
Administrative and Clinical Support Staff Jobs and Responsibilities
Common job titles for support staff:
- Clinic coordinator
- Medical administrative assistant
- Clinical medical assistant
- Medical records specialist
- Medical billing specialist
- Financial counselor
- Scheduler
Responsibilities:
- Scheduling appointments
- Answering phones
- Greeting patients
- Maintaining medical record
- Assisting providers during exams and procedures
- Performing measurements
- Processing billing
- Completing insurance forms
- Performing laboratory or other diagnostic services
- Managing financial records
What does team-based patient care provide a partnership between?
Team-based patient care between providers and patients ensures that patients are educated and involved in their care at all times.
Resources to Coordinate Care With Community Agencies
- Brochures from organizations are usually free and available to hand out.
- Keep a list of community resources in an easily accessible location so that information can be provided to patients without any delays.
- Depending on the specialty of the practice, lists can be organized according to patient condition, age, or socioeconomic status.
-The CDC website has resources that provide services within specified geographic locations and does not require a fee or someone to receive federal or local resources to be eligible. - Local hospital websites also provide information regarding outreach programs offered in the community.
- Document all information provided to the patient in the health record to promote continuity of care.
Suggested Regular Screenings
Suggested screening times are based on adults who have an average risk. However, an increased risk for the disease might be indicated if there is a family history of the disease.
- Blood pressure
- Breast cancer
- Cervical cancer
- Colorectal cancer
- Cholesterol screening
- Dental examination
- Lung cancer
- Bone density
- Diabetes
- Dilated eye examination
Blood pressure screening
Risk factors include African American race, being overweight, family history, and previously recorded higher than normal blood pressure.
Breast cancer screening
A mammogram is an x-ray of the breast to help identify cancer.
The American Cancer Society recommends that screening starts at age 40.
Cervical cancer screening
A Pap test is used to help identify cervical cancer.
Recommendations include every 3 years from age 21 to 29 years.
For patients age 30 to 65 years, recommend screening every 3 or 5 years if having a Pap test and a test for human papillomavirus (HPV).
Colorectal cancer screening
This is recommended starting at age 45 and can be done by performing a fecal occult blood test (FOBT) to detect blood in the stool or colonoscopy.
If FOBT is positive, a colonoscopy will be recommended.
Cholesterol screening
Adults who have a family history of high cholesterol levels may need to be tested more regularly.
