Class 4 - Practice Transformation & Community Engagement

Question 1

Triple Aim

Answer 1

1. Experience of care
2. Health of a population
3. Per capita costs

Question 2

Patient-centered care

Answer 2

Providing care that is respectful of and responsive to individual patient preferences, needs, and values - ensuring that patient values guide all clinical decisions

Question 3

PCMH

Answer 3

A care delivery model whereby patient treatment is coordinated through the primary care physician to ensure patients receive the necessary care when and where they need it, in a manner they can understand

Question 4

Benefits of PCMH - Patient Care & Outcomes

Answer 4

• Enhanced patient and staff satisfaction
• Access to tools to manage patient populations, i.e., disease registries, health information exchanges
•  Improved communication among staff and patients through patient portals and other innovative communication vehicles
•  Care coordinated and integrated across all elements of the healthcare system

Question 5

Benefits of PCMH - Work Environment

Answer 5

• Workflows and efficiencies customized to the practice
• Providers/staff working at the top of their licensure/certification
• Team-based approach to providing care
• Achieve recognition for the work already performed
• Staff satisfaction

Question 6

Benefits of PCMH - Financial Incentives

Answer 6

• Incentives and enhanced payment for achieving PCMH recognition
• Providers able to share in DSRIP funds once PPS is successful in meeting metrics; PCMH aligns with DSRIP goals

Question 7

PCMH standards

Answer 7

add

Question 8

APC gate 1 (technical assistance for care transformation)

Answer 8

Commitment and preparation

• Practices must show evidence of commitment to change
• Shared responsibility among payers and providers in the region is needed to ensure that payers participating in financially supporting APC represent a critical mass of the practice’s panel (60% of practice’s patients)

Question 9

APC gate 2

Answer 9

add

Question 10

APC gate 3

Answer 10

add

Question 11

Health equity

Answer 11

The means that everyone has a fair and just opportunity to be healthy

Question 12

Health disparities

Answer 12

Inequalities that exist when members of certain population groups do not benefit from the same health status as other groups

Question 13

Health literacy

Answer 13

The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions

Question 14

Social and economic factors in health inequity

Answer 14

Social and economic factors = 40% in addressing health inequities; other 60% = 30% healthy behaviors, 10% physical environment, 10% access to care, 10% quality of care

Question 15

Social and economic factors in health inequity

Answer 15

Social and economic factors [education, employment, income, social support, community safety] = 40% in addressing health inequities; other 60% = 30% healthy behaviors, 10% physical environment, 10% access to care, 10% quality of care

Question 16

Medical neighborhood

Answer 16

A clinical-community partnership that includes the medical and social supports necessary to enhance health, with the PCMH serving as the patient’s primary hub and coordinator of health care delivery