The document describes the implementation of a patient centered medical home (PCMH) at Saint Peter's University Hospital (SPUH) Family Health Center in New Jersey. The PCMH aims to improve healthcare for New Jersey residents and decrease costs through a federally sponsored public health project. Key goals of the PCMH include reducing admissions and emergency room visits, improving care processes, and increasing patient satisfaction. Initial results show increased patient satisfaction and decreased wait times.

1. The
Implementa,on
of
a
Pa,ent
Centered
Medical
Home
Jacqueline
Veress;
Margaret
Drozd,
MSN,
RN,
APRN-­‐BC,
Director
of
Community
Mobile
Health
Services;
Tara
Gunthner,
BSN,
RN-­‐BC
• The
Delivery
System
Reform
Incen,ve
Payment
(DSRIP)
Program
is
a
federally
sponsored
and
state
funded
public
health
project.
• It
is
designed
to
improve
the
healthcare
of
NJ
residents
and
decrease
costs.
• Pa,ents
are
recruited
from
SPUH
outpa,ent
services,
the
emergency
department,
inpa,ent
services,
same-­‐day
services,
and
community
health
screenings.
• The
PCMH
is
based
at
SPUH
Family
Health
Center
in
New
Brunswick,
NJ.
• The
desired
outcomes
are
reduced
admissions,
reduced
ER
visits,
improved
care
processes,
and
increased
pa,ent
sa,sfac,on.
Results:
• Increased
pa,ent
sa,sfac,on
• Decreased
wait
,me
• Pa,ents
are
sa,sfied
from
the
range
of
good
to
very
good
(4-­‐5)
• Low
socioeconomic
adults
have
twice
the
mortality
rate
from
diabetes
than
high
socioeconomic
adults.
• Factors
that
contribute
to
disease
in
this
popula,on:
• Financial
issues
• Medica,on
noncompliance
• Lack
of
understanding
of
disease
processes
• The
PCMH
model
has
shown
significant
results
for
pa,ent
self-­‐management
of
chronic
diseases,
pa,ent
sa,sfac,on,
and
cost
reduc,ons.
• To
Implement
a
pa,ent
centered
medical
home
• Target
popula,on:
• Nonpregnant
adults
• Uninsured
or
underinsured
• Diabe,c
• Hypertensive
Purpose
Significance
Methods
Evalua,on
Outcomes
Improved
popula,on
health
and
cost
reduc,ons
will
be
evaluated
through
electronic
medical
records
and
pa,ent
sa,sfac,on
surveys.
Pa+ent
Sa+sfac+on
for
2014
Ques+ons
Range
Acknowledgments
Thank
you
to
Margaret
Drozd,
Director
of
CMHS;
Tara
Gunthner,
Internship
Supervisor;
Anne
Marie
Hill,
Internship
Coordinator;
and
the
staff
at
CMHS.
Case
Management
People
Involved:
• Pa,ent
• Family
• Primary
health
care
provider
• Specialists
• Community
supporters
DSRIP
Team:
• Physicians
• Nurse
prac,,oners
• Registered
nurses
• Cer,fied
diabetes
educators
• Social
workers
Services:
• Assessment
• Treatment
• Educa,on
• Follow-­‐up
Strategies:
• Behavior
modifica,on
• Nutri,onal
consulta,on
• Social
services
• Hospital
discharge
planning
• Pa,ent
naviga,on