Pursuing Perfection

The New Direction of Health Care Delivery

There is a profound personal cost to all participants of the current health care delivery system; the benefits of transforming health care in accordance with the six new aims are enormous.
The New Direction will allow real coordination of care that is respectful of patients as whole human beings.
The New Direction will use the Internet to ensure that providers and patients have access to personalized evidence-based information in a useful and timely manner.

Program Elements

Care organized by cross-continuum care teams that include patients, physicians and clinical care specialists; clinical care specialists serve as counselor, educator, and health care system navigator.
Care coordination advanced through agreed-upon cross-continuum chronic disease protocols that are evidence-based and incorporated into a shared care-plan located on a secured Website, and accessible to all team members, including patients.
Healthcare information to support 24/7 clinical decision-making and patient self-management via continuation of our electronic medical record strategy and accelerated development of automated tools to support disease management and associated workflows.

The Plan

Executive participation across multiple organizations to implement program elements.
Implementation of a community-wide Electronic Medical Record among the participating pilot sites.
Implementation of a shared care plan available 24/7 to all members of the care team including patient in the pilot sites.
Implementation of a secured website for patients providing email and access to their critical aspects of their medical record 24/7.
Redesigned primary care practice sites with improved access, patient self- management support, and improved flow across the continuum of care in pilot sites.
Development of new reimbursement models to support patient-centered care.
Patient and staff measurement tools developed and effectively used to plan interventions in pilot sites.