The PCMH Project team met with our funders at the California HIV/AIDS Research Program and statewide cohort in May to share findings and best practices.  There were several shared themes to the presentations: the challenges and benefits of empanelment, and what it takes to create system-wide change.

The Alameda County PCMH Project team shared our successes in expanding panel management within our network and bringing patients back into care, along with the challenges of keeping momentum going in an environment where clinics have many competing priorities.  Our full presentation can be viewed by clicking here (Flash plugin required).

UCSD's presentation explored the idea of breaking down silos, particularly by including IT staff in the clinical care teams.  They also talked about DSRIP V and its contributions to empanelment and added staff.  

The Los Angeles team at OAPP described the beginning stages of implementing a "PCMH Prototype", which consists of Medical Care Coordination and population management using i2iTracks.  One of the main topics of their talk was what a huge challenge it can be to implement change on a large systems scale, especially as employees of an outside organization.  

UCSF discussed strategies for recruiting geriatric HIV patients into the Silver Project. They described the challenge of implementing team-based care and encouraging physicians to let go of tasks that can be handled by other clinic staff.

The team from the C.A.R.E. Program in Long Beach shared the process of connecting their Electronic Dental Record to the EHR, and the challenge of creating seamless information sharing between the two systems.  

• Clarify NCQA PCMH 2011 Standards and documentation requirements
• Review a selection of documents, including all Must Pass Elements, to verify they are sufficient and appropriately labeled
• Provide feedback on potential opportunities to improve your score before submission