The document discusses using patient registries and automated patient outreach to help medical practices qualify for level 3 recognition as a patient-centered medical home according to NCQA standards. It describes how the Phytel system can mine practice data to identify patients for recommended care, contact patients via automated outreach scripts, and generate reports on quality measures and financial results to document improved performance. Using these tools helped one practice profiled achieve the highest level of NCQA medical home qualification.

1. The Patient Centered Medical Home: Using Patient Registries and Automated Patient Outreach to Qualify for NCQA Level 3 Medical Home Joseph Mambu MD CMD CHE November 2009

3. Core Care Components & Infrastructure Components

6. The Current Model of Care: Connection by Billing Insurer

7. The Future Model of Care: Patient Centered Integrated Delivery System Sub-specialty “Medical Home Neighbors” Referrals and Procedures Insurer Patient Centered Hospital Patient Centered Medical Home Data Center

10. PCPCC–THE BUYERS OF HEALTHCARE

12. Which Payment System Is Best? Depends on the Disease/Condition

14. Geisinger Medical Home Sites and Hospital Admissions Source: Geisinger Health System, 2008. Hospital admissions per 1,000 Medicare patients

15. Geisinger Medical Home Pilot Sites Reduce Medical Cost Source: G. Steele, “Geisinger Quality—Striving for Perfection,” Presentation to The Commonwealth Fund Bipartisan Congressional Health Policy Conference, Jan. 10, 2009. Allowed per member per month

16. Cost Savings of DM Management

20. Physician Practice Connections/PCMH January, 2008

27. IMPROVING THE CARE OF CHRONIC DISEASE

28. DISEASE MANAGEMENT

32. PATIENT REGISTRIES

34. MEASURING PATIENT-CENTEREDNESS