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The Patient-Centered Medical Home (PCMH) is a model of care that seeks to reduce and eliminate fragmentation of care through the establishment of a holistic environment that allows patients and their families to receive continuous and affordable health care at a single location/facility. The main mission of a PCMH is to ensure patient access to continuous and comprehensive care.
Two ASU Science of Health Care Delivery Master’s students worked with the NOAH quality improvement coordinator to assess Desert Mission’s current progress towards PCMH accreditation. After this initial analysis, the team selected two must-pass elements to improve from failing grades to passing. The primary focus of this project was the implementation of the use of data for population management. Results: Although the team was able to complete the data analysis, and identify patients of high interest, due to the time constraints of the project, the team was not able to fully accomplish the overall objective of initiating the letter campaign to proactively engage patients to improve population health.
Nevertheless, the team would like to provide the final recommendation of using a text message campaign, as opposed to a letter campaign, due to the transient nature of the local population in addition to the low response rate of letter campaigns. It is our belief that a text messaging platform will increase community engagement and encourage patients to schedule appointments and enhance patient retention. With PCMH accreditation, the Desert Mission Community Clinic will be eligible to receive enhanced reimbursement from Medicare and Medicaid, which is particularly helpful for facilities that emphasize care for low-income, underserved communities.