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By Madeline Hyden, MGMA Web content writer/editor

Primary care practices have an opportunity to get patients, specialists, hospitals and community resources engaged in patient care as a cohesive team. This does not come without roadblocks, though.

By recognizing and addressing common challenges on the way to achieving a patient-centered care model in your primary care practice, you can prepare for the inevitable hurdles ahead.

Patient obstacles The challenges at the patient level include  those who don't follow care-team protocols when seeing physicians or who demonstrate noncompliant behaviors, such as missing appointments or failing to make healthy lifestyle changes such as quitting smoking or losing weight. To create a system that supports the patient as an active member in his or her own care, communicate clearly defined roles and expectations and incorporate change readiness and mutual decision-making into the patient's care coordination process.

Physician/practice obstacles Physicians frequently struggle to communicate their needs to their care-team members. This lack of communication worsens when the care team involves outside specialty providers and multiple facilities, and there is rarely one person in charge of a patient's overall care. To prevent reactive measures to patients' needs, reach out to patients to schedule follow-up appointments or discuss prescriptions instead of waiting for them to call once they need something.

Facility obstacles Lack of electronic health record (EHR) system interoperability between hospitals and practices, and no recognition of outside providers often prevents timely follow-up care and the exchange of real-time patient information. Again, soliciting hospitals for discharged patients' information and follow-up care closes the gap between hospital care and the patient's care team.

Community obstacles Community obstacles are similar to facility obstacles in that there is a general lack of communication between the primary care physician and outside entities, such a community support groups.  Defining the roles of various community-based organizations and ensuring patients communicate their involvement with them improves care coordination

The Patient-Centered Medical Home Care Coordination Workbook, a part of the Transformation Series by TransforMED, provides information about how to move your practice toward patient-centered care The Transformation Series focuses on practice redesign to help maintain and enhance the sustainability of primary care in the ever-changing healthcare environment.

See more TransforMED workbooks on care access for patients and deciding whether a PCMH model is right for your practice.


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