Patient-Centered Medical Home and Chronic Care Model

Dates: 2009-2010

State: Colorado

Client(s): Metro Community Provider Network

Services: Health Care & Public Health Planning, Training & Technical Assistance, Health Systems Transformation

Technical Expertise: Aging, Chronic Disease Management, Health Care Reform, Integrated Care Models, Primary Care, Safety Net

Patients with exceptional health care needs are likely to benefit greatly from patient-centered, comprehensive, well-coordinated health care services. Seeking to provide better care for such populations, Metro Community Provider Network (MCPN), a federally qualified health center in Colorado, asked JSI to help create a new operations model for their Potomac Street Health Center (PSHC), a clinic that serves an older adult population with chronic and complex health conditions, as well as individuals with physical and developmental disabilities.

JSI analyzed PSHC's services, operations, electronic health record and current users in terms of number, demographics, and health status to determine gaps between current and ideal state. JSI also conducted an external review of community resources, referral partners and potential collaborators. Once the medical home and chronic care models were in place, JSI created an evaluation plan and assisted in conducting the evaluation that allowed PSHC to determine how effectively it was implementing the care models and if they were producing the desired results.

In March 2011, MCPN received the highest level of patient-centered medical home recognition—Level 3—from the National Committee on Quality Assurance (NCQA).


Related Resource