Collaboration. Integration. Quality.

CONTACT HITCH INFO@HITCH.ORG
914-488-6400

DIABETES CARE

IMPROVING QUALITY, EFFICIENCY AND COORDINATION OF CARE THROUGH THE PATIENT CENTERED MEDICAL HOME

The PCMH Care Coordination project aimed to improve quality, efficiency and coordination of care for persons with diabetes through the Patient Centered Medical Home  model at three federally qualified health centers (FQHCs) supported by an interoperable health information infrastructure. HITCH worked with the PCMHs to accomplish the following goals:

  • To develop the interoperable health information infrastructure necessary to enable health information exchange among providers in the PCMHs, as well as other identified stakeholders,
  • To conduct health information exchange with the Taconic Health Information Network and Community Regional Health Information Organization (THINC RHIO) and the SHIN-NY,
  • To improve coordination and management of care for 5,000 patients with diabetes through the health information exchange.
  • To achieve recognition from the National Committee for Quality Assurance (NCQA) as a Level 3 Patient-Centered Medical Home for each of the three partnering FQHCs.

Other benefits of the health information exchange for the stakeholders, participants and patients include e-prescribing; enhanced medication management; creation of patient portals and/or personal health record, including adoption of a pilot portable PHR specific to migrant and seasonal farm workers, data collection and distribution of quality measures, and improved tracking, monitoring, and follow-up on labs, x-ray, referrals, and hospital discharge summaries.

This project was funded by a Phase 10 Heal NY Grant from the New York State Department of Health.