In addition to the state program, The Corvallis Clinic is also certified by the National Committee for Quality Assurance and is piloting a federal health care program under Medicare, said Mohamed Alyajouri, Director of Quality Improvement & Informatics at The Corvallis Clinic. While The Clinic already met many of the quality measures for state certification, there were several changes that have come about through the certification process, Alyajouri said.
For example, a doctor from The Clinic's new care coordination team now visits Clinic patients who are admitted to the hospital. And when the patient is discharged, a nurse calls to check in and to schedule a follow-up appointment with his or her primary care physician. Research has shown that following up with a recently discharged patient decreases the likelihood that he or she will be readmitted to the hospital.
Doctors are using technology to track which of their patients are due for important screenings, such as colonoscopies, mammograms and cholesterol checks. Instead of waiting for patients to come in when they are sick, the new approach is for the doctor's office to call patients to let them know about preventive care measures they can receive. Patients also can access their health information online through the patient portal,
www.myclinicconnection.com. Instead of waiting for test results or wondering about immunization records, they can see them through a secure website. This proactive approach to medicine is transforming health care, Alyajouri said.
"Instead of just treating patients, we're keeping them healthy," he said.
Doctors' offices are also changing their appointment books so there's time to add patients who need to be seen right away. In the old model, patients who called for an appointment could have waited weeks to get in, said state analyst Creach.
"The new model is you are able to get the care you need," she said, "and your care team is available when you need them."
Learn more: Oregon Health Authority has more information and stories about the Patient-Centered Primary Care Home at its website, www.primarycarehome.oregon.gov.