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Provider Toolkit

PW_E191344

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.  
Resources: 
Referral Forms and User Resources
The intent of this guide is to identify the fields and values needed when completing the Referral Form. It includes a legend with definitions along with step by step directions for submission.  
Region/and or State specific online referral form for Empire care management programs.  
Description of programs that are offered to help patients improve their own health in partnership with their primary care physician.  
Other Resources
Empire worksheet introducing the concept of medication reconciliation and related implementation strategies.  
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 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. 
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. 
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. 
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. 
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 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.  
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. 
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.  
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. 
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