Since 2004, SNI has offered a robust series of primary care improvement initiatives to our CAPH-member hospital systems including: the Chronic Care Learning Collaborative (CCLC), Spreading Effective and Efficient Diabetes Care (SEED), Patient Visit Redesign (PVR), and the Seamless Care Center Initiative. We aim to expand our primary care improvement efforts to further support the development and spread of primary care medical homes in all California public hospital clinics.
SNI/CAPH endorses eight core components that define a medical home:
1. Care is tailored to the patients’ health needs
2. A team of providers is responsible for the patients’ care
3. Patients are engaged in their own planned, whole-person care
4. Care is continuous, comprehensive and coordinated
5. Care is driven by measures and supported by technology
6. The patient has access to care
7. The patient and the care team engage in open and effective communication
8. Reimbursement should adequately reflect the cost and value of medical homes
SNI’s Building Medical Homes program aims to move all public hospital primary care clinics closer to achieving the medical home components outlined above. SNI will strive to provide a tailored approach to each CAPH member’s needs. One component of the program is a collaborative that will help clinics from several CAPH member hospitals become high performing medical homes with a particular focus on improving chronic illness care for diabetes patients. Using IHI’s Model for Improvement and the Care model as roadmaps, SNI will provide the structure and coaching to help clinic teams measurably improve care for the patients they serve.
SNI will also host in-person forums for ambulatory care leaders to facilitate in-depth sharing of best practices and challenges around the medical home. Additionally, SNI will host its third statewide Primary Care Workgroup webinar series which will be focused on optimizing the care team in 2012.
Contact: Denise Gonzalez, MD