Table 3.

Key Stakeholder Perspectives of IPC Tasks that PCMH Teams Could Perform

Tasks PCMH teams could perform	•Answering/returning phone calls •Care coordination •Virtual in-home assessments •Supporting patients during care transitions •Patient/caregiver education •Medication reconciliation •Intensive follow-up •Case management •Relationship building with patients and caregivers •Medication management	•Psychosocial support •Panel management •Interdisciplinary teamwork •Huddles •Complex case conference •Use existing tools for neurocognitive/memory issues •Intensively manage small panels of patients •Referrals to community services
Tasks PCMH teams could not perform	•Home visits •Co-attending appointments with other clinicians •Same level of intensity [as IPC teams] • “Being on top of appointments” • “Being on top of medications” •Identifying community resources	•Engaging hard-to-reach patients (e.g., homeless; cognitively impaired) •Services outside the outpatient setting •Respond quickly to patient calls •Individualized care plans •Quicker access to care •In-depth assessments or chart reviews •Intensive case management