Care Coordination for Primary Care Practice

Primary care practice coordination versus physician continuity.

BACKGROUND AND OBJECTIVES This study assesses the influence of primary care continuity--both clinician and system--on patient outcomes. We consider the presumed benefits of physician continuity and practice coordination within a multi-specialty group. METHODS The practices of 194 family physicians and general internists caring for 320000 adult members of a health maintenance organization were...

Improving Care for the Frail in Nova Scotia: An Implementation Evaluation of a Frailty Portal in Primary Care Practice

Background Understanding and addressing the needs of frail patients has been identified as an important strategy by the Nova Scotia Health Authority (NSHA). Primary care (PC) providers are in a key position to aid in the identification of, and response to frailty as part of routine care. Unlike singular chronic conditions such as diabetes and hypertension which garner a disease-based appr...

Primary Care Practice Transformation

Implementation of "Chronic Care Model" for Diabetes Care in Iranian Primary Health Care: Does it work?

Objective: Traditional health care systems were not capable to face successfully with chronic diseases including diabetes mellitus. In this regard, the Chronic Care Model or CCM was created to promote quality of care. The aim of this study was to examine whether establishment of chronic care model, with focus on diabetic patients, has led to clinically significant outcomes in Iran. Materials a...

Using Clinical Microsystems to Implement Care Coordination in Primary Care

Objective: Care coordination is a core competency for primary care nurses and an essential element of the Patient Centered Medical Home (PCMH) model. Implementing care coordination in primary care is challenging and requires changes in roles, staffing, and culture. Clinical Microsystems are frontline teams of healthcare staff that, when engaged in quality improvement, can make important contrib...