Supporting members who practice in a mature Patient Medical Home model, where two or more physicians work together with a collaborative team to manage their patients.
All benefits of Standard membership, plus:
PMH Team
The PMH team includes the following CWC PCN team members:
- Health Information Coordinator: Supports physicians and PMH team members in EMR/data management and the implementation of improvement projects aimed at improving overall patient outcomes.
- Patient Care Coordinator: Supports the coordination of planned care aimed at improving screening and management of patient care.
- Improvement Associate: Facilitates physician-led improvement projects that underpin the Patient Medical Home model of practice.
- Measurement & Evaluation Consultant: Provides analytic support to the physician-led PMH team.
- Primary Care Registered Nurse: Performs a detailed assessment and utilizes modalities, such as health education, lifestyle modification and chronic disease management, to deliver preventive health services and encourage patients to become active participants in their own health.
- Behavioural Health Consultant: Provides short-term behavioural and psychological interventions to address a wide range of psychosocial health concerns with the goals of early identification, quick resolution, prevention and health promotion.
PMH Services
Team members work with Comprehensive physicians in the same clinic to manage patient care for shared patient populations. For example, if both physicians have a large patient population with diabetes, then shared clinic processes and care pathways are developed to manage this patient group.
In addition to in-person patient care, the CWC PCN is introducing a digital health option to increase access to the Patient Care Team through secure email, text and video conferencing. This technology will also improve team collaboration by connecting staff at different locations.
Examples of how we support our members:
- Helping members to identify and maintain their patient panel
- Optimizing the EMR to support patient care. This may include:
- Assisting with the development of standard data entry processes for recording patient information
- Creating documentation of standard EMR processes
- Identifying care pathways for delivering patient care and self-management support
- Providing care coordination support relating to improvement goals. This may include:
- Managing requisitions
- Conducting outreach or opportunistic screening activities
- Assisting with external referrals
- Ensuring test results (e.g., lab, DI) and external communications are in the EMR
- Measurement and analytic support including:
- Developing evidence-informed search criteria to identify patients for screening or chronic disease management
- Tracking changes over time (e.g., tracking time for patients to get an appointment; tracking patient outcomes resulting from process changes for chronic disease management)
- Data collection, data analytics and reporting (e.g. a report that describes a patient panel; reports that identify patients eligible for Complex Care Plans)
- Providing patient outcome information to enhance care delivery
- Supporting Occupational Health and Safety
- Providing OHS resources (first aid kit, Material Safety Data Sheets)
