Complete care management through teamwork enabled by emerging healthcare technology

A key innovative care management is support for specialty care access, eConsults bridge the gap in electronic health record (EHR) systems to improve provider communications and care coordination in support of the patient-centered medical home (PCMH) model.

Patient demographics and disease trends are driving the evolution of healthcare toward an increasingly patient-focused system centered on primary care. In this environment, primary care physicians (PCPs) play a pivotal role in the team management of patients with complex chronic conditions. They are adept at balancing traditional disease-based approaches with individual patient and caregiver preferences.

Long-term relationships with their patients and community service providers across the continuum of care uniquely position PCPs to effectively individualize care, thereby increasing both patient and provider satisfaction, while enhancing the quality and cost-effectiveness of innovative care  management.

Such holistic, patient-centered care requires consistent, coordinated, and team-based medical practice rooted in evidence-based medicine, as embodied in the patient-centered medical home (PCMH) model.

PCMH is focused on providing access to high quality, comprehensive, patient-centric, and coordinated care. Policy-makers, payers, and health systems have recognized the value of PCPs as quarterbacks for inter-disciplinary care teams across the broader healthcare system, including specialty care management, hospitals, home health care, and community services.

Coordination is especially critical during transitions between sites of care, such as when patients are discharged from the hospital to their home or a rehabilitation center. During this vulnerable transition, clear and open communication among patients and families, the medical home, and members of the broader care team are essential for positive patient health outcomes.