HealthPartners’ ‘Care Model Process’ Creates a Patient-Centered Medical Home

HealthPartners Medical Group used its “care model process” to create a patient-centered medical home by developing primary care workflows that provide a consistent clinical experience for patients and their care teams. Standardized processes and clearly defined roles for staff enable the care teams to create a “continuous healing relationship” with patients.

Excerpted from:

Commonwealth Fund’s Case Study: Organized Health Care Delivery Systems HealthPartners: Consumer-Focused Mission and Collaborative Approach Support Ambitious Performance Improvement Agenda By Douglas McCarthy, Kimberly Mueller, and Ingrid Tillmann, Issues Research, Inc.

“HealthPartners clinics have adopted a ‘care model process’ that defines a standard set of workflows for delivering evidence-based care. The process establishes consistent practices for care teams which provide a consistent clini­cal experience for patients.Clinic staff members are organized into ‘prepared practice teams’ composed of a physician, a rooming nurse, a receptionist and others such as a pharmacist or dietitian, when needed, to meet patient needs. The goal is to create a ‘continuous healing relationship’ between the care team and the patient by mak­ing the best use of collective team skills, enhancing communication, and ensuring that care is well-coor­dinated and responsive to patient needs.

These teams typically huddle each morning to review their schedule and objectives and plan for the day. Teams plan for patient interactions in defined cycles which include, scheduling, pre-visit, check-in, visit, and post-visit. Defining the elements of the interaction with patients allows the care team to anticipate patient needs, remind patients of health issues, and provide follow-up after the visit.

For example, pre-visit plan­ning may include identifying preventive care services that will need to be provided at the visit and contacting the patient to schedule lab tests before the visit so that results are available for review during the visit. At the patient visit, the team uses the EHR to address the patient’s health maintenance or chronic care needs, prescription refills, and schedule future appoint­ments. Patients receive an “after-visit summary” to promote better adherence to treatment and to receive outstanding lab results by their preferred method of notification (letter, phone, or online).

The care model process enabled HealthPartners Medical Group to become one of the first large multi-specialty group practices in the nation to be recognized as a Patient-Centered Medical Home by the National Committee for Quality Assurance Physician Practice Connections-Patient-Centered Medical HomeTM

Keywords: access, after-visit summary, care coordination, care model process, care team, communication, EHR, electronic medical records, evidence-based medicine, health information technology, HealthPartners Medical Group, medical home, Minnesota, NCQA, patient-centered medical home, patient support, preventive care, team huddles


Amy von Walter
Director, Corporate Communications
8170 33rd AvenueSouth
Bloomington, MN 55425
tel. 952.883.5274

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