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Transcript of ECDC--PCMH Model

prezi tutorial
Diego's Journey
A Patient Centered Medical Home
Meet Diego
Diego is sick
He complains of a sharp pain in his ear, congestion, and bad headache.

How do we provide Diego with PCMH care?

Let’s begin...

Staff Roles
How do YOU fit in?
Mom, what are we going to do? We don't have a scheduled appointment.
Same Day Appointment Access
Appointment with PCP
Erica updates any changes to their insurance, income citizenship/residency status, family size , phone number, or address.

If Diego was a new patient…
Diego would have been give a New Patient Brochure.
New Patient Brochure: Includes information about importance of PCP, the role El Centro plays as a medical home, patient rights and responsibilities, financial aid to cover costs of services, hours of operation and much more. :)
Diego(Mom mostly)would choose his PCP and see that provider for the majority of his visits with the clinic.


Diego's MA, Lorena, is
as Diego speaks English, but his mom only speaks Spanish.
Lorena records a
detailed medical history
and checks if Diego's
vaccines are up-to-date
During well exams, Lorena uses
questionnaires to document Diego's development
for Dr. Landry to review.

Dr. Landry
leads Diego's medical care team
develops a personalized care plan
according to Diego's needs and family preferences.
Dr. Landry
orders labs and follows up on all lab results in a timely manner.
Dr. Landry is able to communicate with Erica (Diego's Mom) via the
patient portal
to follow up on Diego's health.
Dr. Landry
works with other members of Diego's care team
, such as the dentist, behavioral health specialist, case manager, registered dietitian, clinic manager and referral specialist to manage Diego's care and offer Diego all of the help needed for him to develop and be as healthy as he can be.

Priscilla sees that Dr. Landry inputs a referral to the ENT.
She works to track and manage the referral.
In this case, Diego has Medicaid so she finds a provider that accepts his insurance plan & schedules an appointment.
Sends all relevant info to referral facility, follow-up & requests reports.
Lastly, she scans results in chart for Dr. Landry to review.

Thanks to El Centro's PCMH Team, Diego is now ready to conquer the world!

Diego's visit may be randomly chosen to participate in patient satisfaction surveys.
We want patient feedback about access, communication, coordination, and whole person care/self-management support
QM analyzes data and investigates methods for a better patient experience
And trust me... if those vaccination records aren't complete, we'll know and recall him back to keep him up to date.
We're always watching...:)
No worries, mijo! Let's call El Centro!
Appointments by patient preference and need
Hello, This is El Centro de Corazon. How may I help you?
Hello. My Diego is sick and he needs an appointment today.
Absolutely, I see Dr. Landry is his PCP. She is available at 10:00am today. Is that time convenient for you?
Short Wait Time
Culturally Tailored Patient Education
Diego would visit Ermy if he needed nutritional advice and support.
Diego would have a blast working with Silvina on any BHS issues he needed support with.
Gotta keep those teeth clean and healthy too!
Arlette helps Diego check-out and reminds him of his next well child exam. She smiles and reminds him to "Stay Healthy".
Mica discharges Diego. Mica gives Erica a flyer inviting Erica to the next child development workshop. She gives Erica a summary of Diego's visit with a copy of his care plan in Spanish.
But wait!
We are not done yet..
Full transcript