Patient-Centered Medical Home
Patient Centered Medical Home is defined by American Academy of Family Physicians as a primary care practice which integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience, and optimal health throughout their lifetimes.
The Primary Care Innovation Model will support the mission and goals described in the UCLA Health System Strategic Plan 2011-2015: Shaping the Future and begin to bridge the gap between our aspiration and reality. We will continue our lead in shaping the future of human health. The Innovation Model is aligned with the objectives of the UCLA Innovates HealthCare Initiative.
- Increase Covered Lives under UCLA Management: UCLA will move forward to increase covered lives in a defined timeframe.
- Practice Re-Design (Patient Centered Medical Home - PCMH): Implement PCMH using select parts of Delivery System Reform Incentive Payments (DSRIP) as presented by Dr. Sam Skootsky, CMO and implemented by FPG Population Health Director, Jordan M. Hall with selected extensions and in a phased manner.
- Patient-Centered Medical Home: Adult/Family Medicine/Patient-Centered Medical Home. Patient-Centered Medical Homes will be developed that focus initially on adult enrollees/patients. Chronic care management programs will be identified and developed.
- Integrate Patient-Centered Medical Home/Primary Care System: The primary care system will be fully integrated across primary care re-design, Patient Centered Medical Home projects, CareConnect Project implementation, and other efforts touching primary care, to accomplish Population Health Improvement measured by defined quality, service, and revenue/cost metrics. This will require program integration, with streamlined interfaces as CareConnect with implementation. These will be defined by the Design Team and overseen by the Leadership Team.
- Expand Both Primary Care System Capabilities and Innovation
- Expand Primary Care System to Accommodate the Increased Capacity: Refine and expand the Primary Care System to be effectively distributed and the preferred point of entry for enrollees/patients. Contemporary practice, “pre-primary” care, and IT will be deployed to develop innovative practice. This will encompass all primary care delivered by the UCLA Clinical Practice Networks (CPNs): General Internal Medicine clinics, Santa Monica Bay Physicians, Family Medicine. Best practice extensions with models to broaden the primary care physician and medical assistant roles including the definitions and expansion of Grand-Aides to increase the training and scope for medical assistants to be embedded case managers. This will require a defined curriculum and set of clinical and workflow protocols and satisfaction measures. Primary Care will be delivered in a series of integrated, geographically-dispersed “nodes” within the UCLA Health System, while pre-primary and other community-based and supplemental services will be delivered by UCLA and partner organizations and extenders in other settings and directly to patients/enrollees remotely. Care coordination protocols including workflow and satisfaction measures will be developed and tested in the practices.
- Expand Innovative Practice: The Innovation Institute and the 1115 Waiver Medical Home project will put time, energy and funding into supporting the development of an “Innovation Practice” that will focus on adult Medi-Cal managed care, with hospitalization at Harbor and Olive View in most circumstances. This will be supported by the development of tele-consult programs for specialty access (to specialists in both UCLA and the County system), and implementation of collaborative hospitalist and tele-ICU programs between UCLA and the County.
- Intermountain Collaboration for Specific Values Best Practices: A UCLA/Intermountain Collaboration will be established to identify, accelerate, and scale best practices for use within and between the two organizations, their leaders and colleagues.
- Replicability within UCLA and Externally: Teams will be established within UCLA and between UCLA and the University of California Office of the President and California operations; and, with other external inspirational and motive partners. In partnership with AAMC, learning collaboratives will be established with small groups of Academic Medical Centers who desire to replicate the Primary Care Innovation Model and other Initiatives that advance UCLAs goals to implement Population Health Management Initiatives. Defined objectives, timeframes, and accountable parties identified.