Fast, efficient care transition

Coordinate patient care transition via a secure, web-based platform.

Combining a referral management platform with access to eConsults enables efficient patient care transition — reduces risk, lowers costs, and improves outcomes.

Patient Care Transition

eConsults: An emerging tool to advance the PCMH model of care

In this blog, we discuss the patient-centered medical home (PCMH) model, and eConsultation as a case study in building HIT resources that support the PCMH model of care. This allows organizations to focus on the patient care transition and align technology support to workflows that serve clinicians and the decisions they have to make for their patients.

The Increasing Importance of Primary Care

An aging population, the rising incidence and prevalence of obesity and other chronic conditions such as diabetes, heart failure, and anxiety/depression, and the wide variety of information sources for patients are factors radically altering the healthcare landscape.

Patient Care Transitions

These drivers are shifting a previously physician-centric and hospital-focused healthcare system toward one that is increasingly patient-focused and primary care centered. In this new environment, primary care physicians (PCPs) play a pivotal role in the team management of patients with complex chronic conditions. They are skilled in factoring biopsychosocial considerations with traditional disease-based approaches to give a holistic response to the health needs of their patients, in ways that reflect individual patient and caregiver preferences.

Long-term relationships with their patients and service providers across the continuum of care, position PCPs to best help individualize care in the most appropriate setting; thereby increasing both patient and provider satisfaction, while enhancing the quality and cost-effectiveness of care delivery.

Embracing the PCMH Model

Such holistic patient-centered care, which places a premium on patient engagement and self-management, requires consistent, coordinated and team-based approaches. Policy-makers and payers (both public and private) have recognized the importance of these attributes and are encouraging primary care to explore new interdisciplinary teamwork practices to deliver effective care management.

In response, primary care teams are adopting evidence-based models, such as the PCMH model of care. The Agency for Healthcare Research and Quality (AHRQ) defines a medical home as an organizational model for primary care that delivers the core functions of primary healthcare with improvements focused on providing access to high-quality, comprehensive, patient-centric, and coordinated care.

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