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Organized, Evidence-Based Care


Organized, evidence-based care (OEBC) is care that is based on scientific evidence and planned and delivered so that the team optimizes the health of their entire panel of patients. OEBC in a Patient-Centered Medical Home (PCMH) consists of designing each encounter to meet a patient's preventive and chronic illness needs, using planned interactions and ensuring appropriate follow-up care. Evidence-based guidelines are embedded into daily clinical practice as well as shared with patients. High-risk patients are identified to determine they are receiving appropriate care management services.

Key changes for Organized, Evidence-Based Care:

  • Use planned care according to patient need.
  • Identify high-risk patients and ensure they are receiving appropriate care and case management services.
  • Use point-of-care reminders based on clinical guidelines.
  • Enable planned interactions with patients by making up-to-date information available to providers and the care team at the time of the visit.


Organized, Evidence-Based Care Resources

Implementation Guides

Organized, Evidence-Based Care Executive Summary

Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations
This Implementation Guide begins by introducing the Chronic Care Model and examining the connections between it and the PCMH, and then focuses on critical aspects of organized, evidence-based care including planned care, decision support, and care management.

To learn more about providing Organized, Evidence-Based Care, visit these pages on our website:

 

Tools

Population Health: Patient Care Reminders Step-By-Step
Share the Care: Assessment of Team Roles and Task Distribution
Workflow Standardization Worksheet
 

Webinars

Planned and Mini-Group Medical Visits (January 10, 2013)
Moderator: Nicole Van Borkulo, MEd, Qualis Health
Speakers: Devin Sawyer, MD, and Jamacca Larman, CMA, St. Peter Family Medicine Residency Program (Olympia, WA)
Audio & video program
Presentation slides

Implementing Effective Clinical Care Management (July 11, 2011)
Moderator: Nicole Van Borkulo, MEd, Qualis Health
Speakers: Ed Wagner, MD, MPH, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA); Kathryn Horner, MS, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA); Rebecca Ramsay, BSN, MPH, CareOregon (Portland, OR); Casey Boland, RN, MSN, Multnomah County Health Department (Portland, OR); Jody Reifenberger, MMS, PA-C, East Boston Neighborhood Health Center (Boston, MA)
Audio & video program
Presentation slides

Organized, Evidence-based Care (June 7, 2011)
Moderator: Nicole Van Borkulo, MEd, Qualis Health
Speakers: Ed Wagner, MD, MPH, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA); Brian Austin, MacColl Center for Health Care Innovation at the Group Health Research Institute (Seattle, WA); Krista Collins, Central City Concern (Portland, OR); John Holmes, PharmD, Idaho State University Department of Family Medicine (Pocatello, ID)
Presentation Slides