A Patient Centered Medical Home

A Patient Centered Medical Home can simply be described as a practice that provides excellent primary care that is delivered by a team and supported by health information technology, and we strive to achieve these goals daily. Faculty, residents, staff and patients are all viewed as peers and partners in our practice.

Our Care Team

Our residents consistently rank our medical assistants and front desk staff as superior in the service they provide to our patients and the support they provide to our resident physicians. Our Medical assistants are an integral part of our team. They huddle with our residents and faculty before each session to review patient needs for the visit, they performing yearly foot exams in patients with diabetes, they complete smoking, alcohol, allergy and depression screening during routine visits, and they perform in-office procedures such as ear lavages, spirometry, urinalysis and oxygen exercise testing.

We also have fully integrated behavioral health, social work and care management services at Uptown Primary Care, and partner with Regis University Schools of Pharmacy to have faculty pharmacists present in our clinic to assist with medication management and drug information topics. It sounds sometimes too good to be true, but we are lucky to have such a talented, diverse and engaged group that makes our lives as physicians much easier, provides extra added care and quality to our patients and allows our faculty to focus on teaching and training.

Visit Types and Electronic Health Record

We provide excellent primary care in the form of multiple types of office visits, including routine follow-up of chronic diseases, acute care visits, preventive visits (including the Medicare Annual Wellness Visit and Transition of Care visits after Emergency Room visits or hospitalizations) and pre-operative assessments.

For each encounter, residents use our electronic health record (eClinicalWorks) to document relevant medical history, assessment, and treatment plan and to bill for the clinical services rendered. It has been reported that it takes 10,000 hours to gain mastery in a subject, so all electronic health records take some time to get used to.

To help you optimize your efficiency with the electronic health record, we have eCW support analysts onsite weekly to help troubleshoot any issues, and our faculty are always willing to help show you a trick or two when using the electronic health record.

The Top 10 Diagnoses seen at Uptown Primary Care

You will be well trained and well prepared in evaluating and managing both chronic and acute medical conditions commonly seen in a general internal medicine setting.

  1. Hypertension
  2. Diabetes
  3. Pain (chest, back, neck, abdominal, joint/soft tissue, headache)
  4. Upper Respiratory infection
  5. Atrial fibrillation
  6. Depression
  7. Congestive heart failure
  8. Edema
  9. COPD
  10. UTI

Demographics and Payer Mix

We serve a diverse group of patients with a balanced payer mix to create a clinical learning environment that provides our residents to develop skills and communication strategies that meets the personalized needs of patients.

Visit Volume and Panel Sizes

In 2017 Uptown Primary Care addressed the health and wellness needs of 7,467 patients. Our expectation is that when our residents complete their training, they will be able to comfortably meet 25% Medical Group Management Association (MGMA) metric of productivity for academic general internal medicine physicians, which is 5.4 patients/half-day session.

Based on 5.4 patients/half-day, the number of sessions a resident has per week (7 sessions), the number of weeks in clinic (7 weeks/year) and the average number of visits per patient in a given year (1.10 visits/year), our goal for resident panel size is 240 patients.

Here is the Equation for Panel Size Calculation:

5.4 patients/session * 7 session/wk * 7 wk/y/1.10 visits/year

Goal Panel Size = 240 patients/resident

eference: Murray M, Davies, M, Boushon B. Family Practice Management April 2007

Quality Improvement and Digital Health

A principle of PCMH is a focus on the quality of care and quality of service provided to patients. Our residents are taught the principles of Quality Improvement, including PDSA cycles, Development of flow charts, cause and effect diagrams, and chart review/registry queries of the electronic health record. Residents use these tools and skills to participate and lead quality improvement programs and initiatives occurring within the clinic.

Residents may also be asked to complete surveys as part of on-going division research addressing patient care and educational issues, and we encourage and advise our residents on how to share the findings of their QI work in the form of a QI H&P, a QI Initiative Summary, abstracts, posters, and oral or written presentations.

Uptown Primary Care is also a host site for the Colorado Digital Health Challenge, which matches Colorado connected early stage health or healthcare technology companies (“innovators”) with key Colorado healthcare organizations and stakeholders (“hosts”). Technology that enhances access to health care and resolve specific opportunities in patient engagement, therapeutic adherence, transitions of care, mental health interventions are targeted and tested in our clinic environment.