Population Health Management

One of the goals of medical homes is to enable providers to know and analyze the health care outcomes of all of that community health center’s patients and identify both overall needs for quality improvement as well as specific patients that may need additional attention and support.

Medical Home Safety Net Initiative, Resources on Organized Evidence-Based Care

Wagner EH, Coleman K, Reid RJ, Phillips K, Sugarman JR. Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes, The Commonwealth Fund (2012)

Willard R, Bodenheimer T. The Building Blocks of High-Performing Primary Care: Lessons from the Field, California HealthCare Foundation (2012)

Wagner EH, et al.  Improving chronic illness care: Translating evidence into action.  Health Aff.  (2001);20(6):64-78

Agency for Healthcare Research and Quality, Computerized Disease Registries

Robert Wood Johnson Foundation Aligning Forces for Quality, Practice Coaching Manual

Weir RC, Emerson HP, Tseng W, Chin MH, Caballero J, Song H, Drum M. Use of enabling services by Asian American, Native Hawaiian, and other Pacific Islander patients at 4 community health centers. Am J Public Health (2010);100: 2199-2205

Association of Asian Pacific Community Health Organizations, Impact of Enabling Services Utilization on Health Outcomes (2009)

Association of Asian Pacific Community Health Organizations.  Evaluation of Culturally Appropriate Community Health Education on Diabetes Outcomes (2008)

Fisher TL, et al. Cultural leverage:  Interventions using culture to narrow racial disparities in health care. Med Care Res Rev. (2007); 64(5):243S-282S

<< Back to Promoting the PCMH Model