A medical home: changing the way patients and teams relate through patient-centered care plans.

The patient-centered medical home model incorporates patient-centered care as a central tenet and espouses the health care team partnering with an engaged patient. The tools to accomplish this type of care have not evolved along with these values. This report describes how the adoption and use of a patient-centered care plan (PCCP) document enhanced care for complex patients and changed the relationships with health team members.

Features of the Chronic Care Model (CCM) associated with behavioral counseling and diabetes care in community primary care.

Background: The Chronic Care Model (CCM) was developed to improve chronic disease care, but it may also inform delivery of other types of preventive care. Using hierarchical analyses of service delivery to patients, we explored associations of CCM implementation with diabetes care and counseling for diet or weight loss and physical activity in community-based primary care offices.

Methods: Secondary analysis focused on baseline data from 25 practices (with an average of 4 physicians per practice) participating in an intervention trial targeting improved colorectal cancer screening rates.

A medical home: value and implications of knowledge management.

Background: Central to the "medical home" concept is the premise that the delivery of effective primary care requires a fundamental shift in relationships among practice members and between practice members and patients. Primary care practices can potentially increase their capacity to deliver effective care through knowledge management (KM), a process of sharing and making existing knowledge available or by developing new knowledge among practice members and patients. KM affects performance by influencing work relationships to enhance learning, decision making, and task execution.

Prostate-specific antigen testing among the elderly in community-based family medicine practices.

Background: Controversy surrounds prostate-specific antigen (PSA) testing for prostate cancer screening, especially among elderly men aged 75 and older. This study examines whether patient age results in differential use of PSA testing and if organizational attributes such as communication, stress, decision making, and practice history of change predict PSA testing among men aged 75 and older.

Methods: Data came from chart audits of 1149 men > or =50 years old who were patients of 46 family medicine practices participating in 2 northeastern practice-based research networks.

What can family medicine practices do to facilitate knowledge management?

Background: Family medicine practices face increasing demands to enhance efficiency and quality of care. Current solutions propose major practice redesign and investment in sophisticated technology. Knowledge management (KM) is a process that increases the capacity of a practice to deliver effective care by finding and sharing information and knowledge among practice members or by developing new knowledge for use by the practice.