Care Delivery Model: Patient-Centred Medical Home (PCMH)
Identify a care delivery model associated with a health outcome within your community. Prioritize risk mitigation strategies to prevent or reduce adverse health outcomes in your community.
Introduction
In my community, the Patient- Centred Medical Home (PCMH) model is used in several primary care clinics. This model emphasizes comprehensive, coordinated, and accessible care, with a focus on quality and safety. By integrating primary care, behavioural health, and preventive services, PCMH aims to improve patient outcomes, especially for individuals with chronic conditions such as diabetes, hypertension, and depression.
Associated Health Outcome
One key health outcome linked to this model in my community is reduced hospital readmissions for patients with uncontrolled type 2 diabetes. Through regular follow-up, medication management, and patient education, the PCMH model has been shown to improve glycaemic control and decrease emergency department visits.
Risk Mitigation Strategies
To further prevent adverse health outcomes related to diabetes and other chronic conditions, the following strategies should be prioritized ,These are:
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Enhance Care Coordination
.Assign dedicated care coordinators to track high-risk patients, ensure follow-up appointments, and facilitate specialist referrals.
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Increase Access to Preventive Services
.Offer same-day appointments, extended clinic hours, and telehealth visits to reduce missed opportunities for timely care.
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Patient Education & Empowerment
.Implement structured self-management education programs, focusing on nutrition, medication adherence, and symptom recognition.
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Data-Driven Risk Stratification
.Use EHR data to identify patients at greatest risk of complications and tailor interventions to their needs.
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Community Partnerships
.Collaborate with local organizations, such as food banks and fitness programs, to address social determinants of health that contribute to poor outcomes. APA
Care Delivery Model
Conclusion
The PCMH model’s coordinated, patient-centred approach already benefits my community, but targeted risk mitigation—especially through care coordination, expanded access, and patient empowerment ,and can further reduce adverse outcomes and improve population health.