Milestone 8: The Medical Neighborhood
Establish external processes/infrastructure to achieve coordination of care
At its core, patient-centered care is not only establishing systematic and proactive care within the walls or your practice but also working on behalf of your patients with the community to coordinate care. The medical neighborhood can include other physicians, specialists, mental health providers, dental/vision providers, hospitals, community resources, social workers, pharmacists, home health care providers, complex case managers, peer programs, and other community supports. The focus is set on the patient while care is accomplished by the medical neighborhood team. Developing the external structure includes establishing relationships to build the medical neighborhood, discovering the types of resources found in the community, setting up communication channels which can enhance patient care and decrease duplication or errors, and tracking referrals, test results, and medications, for overall patient care.
Journey Forward® was launched and has the goals of 1) promoting physician and patient understanding of late effects of cancer treatment and survivorship and 2) to improve continuity and coordination of care for cancer survivors. The site houses tools and resources, including the Survivorship Care Plan Builder, for both health care professionals and cancer survivor patients.
A comprehensive toolkit developed by the Colorado Medical Society PCMH Systems of Care Initiative which walks you and your practice through the process of establishing Care Compacts with specialists you desire to include in your “Medical Neighborhood”.
This sample policy and protocol document comes from a Colorado clinic that has adopted the patient-centered medical home model. It could serve as a template for other practices that want to formalize their care coordination processes.
An example of a formatted checklist (adapted from the Colorado Medical Society Compact Facilitation Guide) that can be used when making referrals as compacted relationships are established.
An example of a formatted checklist (adapted from the Colorado Medical Society Compact Facilitations Guide) that can be used as a stand- alone document or as the first page of a complete response note from the specialist that includes a history and physical (H&P), full evaluation and other relevant information. This should reach the referring and other pertinent providers that are part of the patient’s care team, in a timely fashion, such as within one week of the referral visit if not sooner.
This template referral form provides a way to standardize and track referrals.
This template form is one example of a standard form to send to specialists to facilitate care coordination.
This article from AAFP’s Family Practice Management introduces a standard process for requesting and following up on specialist referrals and consults, and includes a downloadable sample referral/consult form.
This Agency for Healthcare Research and Quality (AHRQ) white paper offers a primer on care coordination in the context of the entire health care continuum, from primary care to specialty and ancillary health care – also known as the medical neighborhood.
This paper from Agency for Healthcare Research and Quality (AHRQ) offers step-by-step guide to planning and implementing a medication reconciliation process in a health care organization.
A policy paper put forth by the American College of Physicians (ACP) based on a three year workgroup on the interface of the Patient-Centered Medical Home with Specialty and subspecialty practices.