Travel Guide to Onboarding Resources

Care Model Approach

Access to Care & Information • Health care for Medicare-eligible individuals • After-hours access to health care providers • Easy access to medical information for patients Practice Management • Disciplined financial management • Cost and benefits factor into decision making • Facilities management Practice-based Services • Comprehensive care for both acute & chronic conditions • Prevention screenings & services • Ancillary diagnostic services such as lab & x-ray Practice-based Care Teams • Primary care leadership coordinates care to help improve patient outcomes • Effective communication • Patient participation • Health education nurses

Health Information & Technology • Electronic medical record

• Electronic orders & reporting • Evidence-based decisions Care Coordination • Collaborative relationships–ER, hospital care & specialist care • Care transition, palliative care & on-site social worker • Patient engagement and education Care Management • Comprehensive patient-focused processes establishing a trusted relationship, streamlining engagement touch-points, and improving coordination within the healthcare team • Focus areas: Patient Engagement; Care Service Alignment; Interdisciplinary Management Quality & DataRap® • Doctors and nurses working with health care analysts to drive outcomes • Evidence-based best practices • Medication reviews

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