Providing Team-Based, Coordinated Care

Preventing unnecessary hospitalizations is a critical strategy for reducing cost of care while increasing the efficiency of health systems.

The Patient-Centered Medical Home (PCMH) is a team-based model of providing care in a coordinated, consistent and efficient way. This approach helps clinicians manage chronic health conditions in a more proactive fashion and access specialists thus reducing unnecessary emergency room visits and admissions.

MaineHealth has a goal that all member-owned primary care practices will attain PCMH Level III NCQA recognition by September 30, 2017. However, not all inpatient admissions can be avoided and once a patient has received inpatient treatment it is important to receive appropriate outpatient treatment to prevent readmission.

As part of the strategy to reduce readmissions, a key strategy is the use of the Transitions of Care Bundle for all patients being discharged. The bundle includes risk assessment, medication reconciliation, timely communication between hospital and outpatient providers and patient education.