Two Way Asychronoous Communication - EHR

The Primary Care Model of the Future 

• Prevention and healing vs. testing and prescribing
• PCMH Team Care: providers and health coaches
• Encounters vs. office visits
• Pro-active Health Risk Assessments
• Technology: EHR, RelayHealth, mobile monitoring
• Address behavioral issues
• Community integration

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New Model - Blends Two Key Elements 

Patient-Centered Medical Home Model 

• Team-based  
• Technology-enhanced and connected 
• Dashboard-enabled 
• Home-based  hub for biometric monitoring 
• Chronic Care Management

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Population Health Management Model

• Health Risk Assessment “Plus” 
• Prescription for better health (shared decision model) 
• Proactive outreach—keep healthy people healthy (apps, interactive tech) 
• Health coaching (live, phone, virtual) to address risk factors and chronic care

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Evidence That it Works

Patient-Centered Medical Home at Walter Reed 

• Reduced ER visits by 6.8% 
• Decreased pharmacy costs by 12.9% 
• Achieved $333 annual cost reductions for chronic care patients 
• Improved HEDIS (quality) scores, as well as access and patient trust