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Weaving the PCMH Model of Care Into Your Operations Learning Collaborative


Session 3: Care Management, Care Coordination, and Care Transitions

Year Developed: 2024

Resource Type: Archived Webinar.

Primary Audience: C-Suite (CEOs, CFOs, CIO, COOs, CMOs, etc.) Clinicians Enabling Staff
Secondary Audience: Board of Directors Outreach Staff PCAs

Language(s): English

Developed by: Renaye James Healthcare Advisors (RJHA) (See other resources developed by this organization).

Resource Summary: The Patient-Centered Medical Home (PCMH) model of care is a way to organize healthcare delivery, coordinate care for patients, ensure the patient's needs are identified, and optimize healthcare outcomes. Despite the various certifications, many feel that a true PCMH is not attainable. This learning collaborative provides a first step in assisting health centers with organizing their approach to communication of the model with their healthcare teams and incorporating the standards into everyday operations.

Resource Details: This session reviews the concepts of Care Management, Care Coordination, and Care Transitions and reviews how technology can assist with closing care gaps and coordinating care.

Resource Topic: Operations

Resource Subtopic: Patient Centered Medical Home.

Keywords: Access to Care, Care Coordination, Chronic Diseases and Care, Education of - Staff (e.g., Competency-Based), Medical Home, Policies and Procedures, Team-Based Care.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $6,625,000 with 0 percentage financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.