1 The Challenge In 2014, MMR Healthcare, a small primary care practice in Boynton Beach, Florida with a focus on geriatrics, recognized that they needed to take a more team-based approach to care to handle a growing number of patients with chronic health conditions, including type 2 diabetes. The Solution Working with eClinicalWorks, MMR Healthcare has earned recognition as a Patient-Centered Medical Home, established team-based care teams, trained patients in the use of Patient Portal, and made full use of HEDIS® dashboards to give them deeper insight into their patients’ overall health. The Results Using the eClinicalWorks Transition Care Management module has driven hospital readmission rates below the national average. HEDIS dashboards mean that instead of waiting

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