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The TransforMED Patient-Centered Model

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The TransforMED Patient-Centered Model

In much the same way that primary care treats the whole person, the TransforMED Patient-Centered Model recognizes that all the elements of a successful Medical Home practice are interrelated, thus the TransforMED approach "treats the whole practice."

Our comprehensive model unites the enduring relationship-centered values of primary practice with new technologies and approaches to enable practices to better serve the needs of both patients and practices.

The benefits of this model continue to emerge from the National Demonstration Project's ongoing evaluation, as well as the pilot projects and practice transformation projects currently facilitated by TransforMED.

The TransforMED Patient-Centered Model

A continuous relationship with a personal physician
coordinating care for both wellness and illness

  1. Mindful clinician-patient communication:
    trust, respect, shared decision-making
  2. Patient engagement
  3. Provider/patient partnership
  4. Culturally sensitive care
  5. Continuous relationship
  6. Whole person care
Access to Care & Information
• Same-day appointments
• After-hours access coverage
• Accessible patient and lab information
• Online patient services
• Electronic visits
• Group visits
• Culturally sensitive care
  Practice Management
• Disciplined financial management
• Revenue enhancement
• Cost-Benefit decision-making
• Optimized coding & billing
• Personnel/HR management
• Facilities management
• Optimized office design/redesign
• Change management
Practice-Based Services
• Comprehensive care
  for both acute & chronic conditions
• Prevention screening and services
• Surgical procedures
• Ancillary therapeutic and support services
• Ancillary diagnostic services
  Health Information Technology
• Electronic medical record
• Electronic orders and reporting
• Electronic prescribing
• Evidence-based decision support
• Population management registry
• Practice Web site
• Patient portal
Care Management
• Population management
• Wellness promotion
• Disease prevention
• Chronic disease management
• Patient engagement and education
• Leverages automated technologies
  Quality and Safety
• Evidence-based best practices
• Medication management
• Patient satisfaction feedback
• Clinical outcomes analysis
• Quality improvement
• Risk management
• Regulatory compliance
Care Coordination
• Community-based resources
• Collaborative relationships
• Emergency room
• Hospital care
• Behavioral health care
• Maternity care
• Specialist care
• Pharmacy
• Physical therapy
• Case management
• Care Transition
  Practice-Based Team Care
• Provider leadership
• Shared mission and vision
• Effective communication
• Task designation by skill set
• Nurse Practitioner / Physician Assistant
• Patient participation
• Family involvement options

Version 2.3.3 Updated October 2009

Copyright 2006-2011 TransforMED. All rights reserved.



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