Improving quality and becoming a Patient-Centered Medical Home is hard work, but these teams are doing it, making believers out of skeptics at their home institutions. Skepticism has been replaced by invitations to present and sometimes lead transformation efforts in other areas of their health systems. They did it, and you can too! Look at your performance data and start making little changes. Check out our online CME to learn more! On Twitter, follow the PAFP at @PAFPandF.               

Here are some of the best practices tweeted on conference day:

Rooming Processes and Provider Visit Essentials:

Choose high-confidence high-priority patient goals for self-management 

Pt readiness & confidence are key in setting achievable pt self-management goals

Your #EMR needs to continuously improve every day, just like your providers & teams; invest in IT specialist

Dial down static in inner-office drama with patient-driven agendas for care, reduce pt frustration, more efficiency

My life got so much better when I matched with a provider-specific MA to "Tee" up pts 

Dr Thomas: I judge my #PCMH success by the degree to which I don't have to be there all the time: effective team members

Leveraging IT to Improve Diabetes Management:

push your #EMR vendor to give you what you want and need

Keep pushing for the latest upgrades to maximize utility of #EMR

Check out your #EMR thoroughly to see what it really CAN do! Check in with other users of the same system

Transition tip from Shadyside UPMC: pill boxes for patients being discharged from the hospital labeled with the practice phone number.  

Medical Records alone don't improve care; must implement meaningful clinical decision support 

Strategies to Improve Adherence among Patients:

Patients and doctors might not have the same objectives. Learn what they are, discuss, engage. Patients might say no. 

Assessing & understanding pt health literacy is key to engaging them in their health management 

Cultural beliefs can affect care. Must communicate to understand & engage them in their healthcare
 

SE Lancaster implemented group visits for #DM, great outcomes, then started group visits for other conditions
 

Nori Harris, RN, group visits to educate pts with common conditions also provide peer support & understanding 
 

See #DM patients quarterly to stay on top of needed preventive healthcare

Support pt to report how they take their meds; help understand challenges & what they need; info, care mgmt, education, $ help 

Pts don't fail at tx; the tx failed the patient: motivational interviewing brings doc onto the same page as pt for collaboration 

Depression is a red flag with patients who do not take their medications as prescribed; Doc must explore barriers to treatment
 

Pt compliance is an archaic concept; Pt concordance is process by which docs and patients collaborate to design tx regimen, buy-in 

NCQA Must Pass Elements:

Dr. Gertner's effort saver: Align your #NCQA #PCMH efforts with your #MU efforts

Gap analysis helps you prioritize and focus your efforts

Data:

Know the measures; know the data; nurture & analyze your data!

I've shared your pain; but we need to be data-driven if we're going to improve the quality of care. Don't give up

don’t be discouraged if performance doesn’t quickly hit goal, at least you’re looking at data (most practices don’t look)

Other subjects:

Great group visit idea: antenatal group into parenting group – great for continuity

Big changes coming for resident training programs: observable milestones and outcomes. #PAIPIP activities help to get PA FM programs ready!

Teams: many outpatient and inpatient EHRs don’t talk & certain computers won't open files from one or both. What other industry accepts that??

Educate patients about ER utilization! What’s an emergency? Remind them to call you with non-emergencies before they go to the ER.

Change fatigue will happen. When it does happen: stop, regroup, refocus and get back at it.