Mission:
Quality, comprehensive, timely, personalized health care

Vision:

1. Optimize personalized, compassionate health care
2. Maintain high quality of care using patient-driven treatment plans, data registries, quality control measures, patient outreach, clinical trials programs, serial process analysis (gap analysis), patient input
3. Prioritize coordination of care by using protocol for timely hospital and emergency department follow up care in office, including retrieval of records
4. Maintain and enhance timely and versatile access to care in various settings
5. Continue to spend significant time with patients, avoiding “high-volume” model
6. Ongoing communications, education (email, portal, other) and other electronic resources (website, links, other) development
7. Encourage utilization of digital and electronic resources among physicians and staff
8. Maintain 24-7 physician availability
9. Continue to develop and utilize cost-effective ancillaries & services
10. Control cost for patients, physicians, and the health care industry

1. Access and Communication
1. Appropriate verbal, written, and electronic communication regarding care access and scheduling
2. Same-day and care-driven appointments
3. Continuity with same provider
4. Phone triage and advice
5. Weekend and after-hours visits when appropriate for quality of care
6. Home visits occasionally as needed when appropriate for quality of care
7. Patient portal and email
2. Care Management and Support (Our team – internal resources)
1. Identification of risk factors (e.g., standardized mechanism for identification of health and risk factors that trigger #2)
2. Evidence-based decision support, guidelines, and reminders
3. Registry functionality (e.g., chronic disease, health maintenance, outreach, other)
4. Data management and outreach (e.g., registry/data outcomes reports [outcome, compliance, cost], patient outreach program, collaborative learning assessments)
5. Tracking and Compliance (e.g., diagnostic tests, referrals, follow-ups, health maintenance, preventive & lifestyle measures, outreach)
6. Hospital and Emergency Room follow-up (e.g., policy & procedures to acutely identify and contact affected patients, retrieve appropriate supporting documents and tests, schedule for appropriate, individualized, short-term follow-up evaluation )
7. End of Life Planning (ranging from advanced directives/living will and planning resources to family meetings and hospice care when needed)
8. Performance measures (e.g., outcomes assessment, patient satisfaction surveys)
9. Education (e.g., emr-driven, printed patient handouts, web-based resources, MA and nurse coordinator teaching, other)
10. Patient-driven goals
11. Motivation assessment and interviewing
3. Care Coordination (Peripheral team – external resources)
1. Access to Nurse care coordinator (key in this area to assist executing care [may be employed by practice/practices, hospital, ACO, payer, etc.], serving as “bridge” to various ancillary & support services, facilitates specialist referrals, troubleshoots social problems and barriers, identifies and troubleshoots non-compliant patients, facilitates outreach, etc.)
2. Hospital and Emergency Room follow-up
3. End of Life Planning
4. Tracking and Compliance
5. Education
6. Self-management support (e.g., printed patient goals and plans, language-specific instructions, patient’s preferences, etc.)
7. Specialists (cost and quality of care mindful)
8. Hospital care co-management (e.g., individualized hospital care/visits coordinated with hospitalist)
4. Comments
1. Some elements in areas 2 and 3 overlap
2. Above measures increase quality of care and decrease cost
3. All above areas significantly decrease hospital admissions/re-admissions and emergency department use
4. All above areas will optimize care and life transitions