Collects, analyzes and tracks data for population health management and actively participates as a team member and facilitator of the Patient-Centered Medical Homes.
Provides data for, and assists the medical homes with proactive outreach to patients to address their health and wellness.
Maintains current working knowledge of the NCQA PCMH Guidelines for PCMH transformation, recognition, and annual review procedures for Patient-Centered Medical Homes.
PCMH quality metric oversight. Monthly quality metrics review and analysis to maintain ongoing quality improvement and identify areas of need with regard to PCMH metrics of success at each location.
Work closely with medical home leadership, physicians and care teams to ensure that the PCMH quality improvement goals are successful. This includes regular communication of the status of PCMH quality improvement projects using Metrics of Success data.
Regional Involvement: Attend regional provider meetings to share and analyze data related to medical homes. Track and analyze data for multiple locations and a variety of practice areas such as Pediatrics, Family Medicine, Adult Medicine, and Geriatrics.
Population Health Assessment: Assist Population Health and PCMH leadership in the evaluation and maintenance of each Medical Home across the region. Ongoing assessments conducted with leadership in each area will determine progress and sustainability of each medical home. Provide data for action plans and make recommendations with leadership in each area using PCMH methodology, identifying barriers and opportunities, as well as validating current state.
Participate in Patient Advisory Council activity across the Regional Sites. This position will be responsible for assisting each Patient-Centered Medical Home's leadership in facilitating the Patient Advisory Council. Assisting the medical home leadership with data for council member recruitment and providing quarterly updates with information on quality improvement activity and care coordination measures will be critical in the goal development and process management of the Patient-Centered Medical Homes in each location. The Medical Home Facilitator will work closely with the Director/Manager of each site to ensure efficacy of the Patient Advisory Council in their respective areas.
Provide data to medical home leadership, physicians, and care teams for continued improvement with team-based care and practice organization, knowledge of the patient population, patient-centered access, care coordination, care management, and performance measurement.
The Medical Home Facilitator is responsible for analyzing and tracking the data for the Patient Centered Medical Home metrics of success. They actively participate as a team member and data resource in the medical homes across the Carle regional sites by working with EMR registries, dashboards, quality metrics and other data sources. They provide data for and assist the medical homes with proactive outreach to patients to address their health and wellness.
Carle Foundation Hospital