Patient Centered Medical Home

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An Overview of Patient Centered Medical Homes

A patient-centered medical home is a model of care that strengthens the clinician-patient relationship by replacing episodic care with coordinated care and a long-term healing relationship. Each patient has a relationship with a primary care clinician who leads a team that takes collective responsibility for patient care, providing for the patient's health care needs and arranging for appropriate care with other qualified clinicians. The medical home is intended to result in more personalized, coordinated, effective and efficient care.

"The Patient-Centered Medical Home is a model of 21st century primary care that combines access, teamwork and technology to deliver quality care and improve health." -Margaret E. O'Kane, President, National Committee for Quality Assurance

Ways we're trying to improve

  • Providing you with a written care plan to make sure you understand and remember how you and your provider are addressing your issue(s)
  • Closing "Patient Care Gaps" by making courtesy calls for outstanding blood work, imaging orders, etc. as well as following up to make sure we get your results
  • Providing you with a clinical summary of your visit each time you ask for one

What this means for patients' health

  • A more active role by the patient in their healthcare
  • Lower percentage of patients being admitted to the hospital
  • Shorter stays for patients who are admitted to the hospital
  • Fewer hospital readmissions
  • Significant overall improvement for many chronic conditions

Patients want to have a close, personal relationship with their provider. They miss it. Providers miss it. PCMH is a way to get back that personal relationship.

Patient responsibilities

  • Ask questions about your illness and take an active role in your care
  • Give a detailed and honest history of your entire family
  • Give an update of any changes in your health each visit
  • Take all medications prescribed as directed by your provider, and provide information about OTC and Herbal Medications that you are taking
  • Keep all scheduled appointments with your provider and other specialist(s)
  • Provide both a personal email address and primary telephone number for easy access and contact
  • Discuss and be involved in your treatment plan with your provider, and follow advice as given
  • Inform your provider of all self-referred visits, or special test(s). Bring documents when available
  • Ensure all discharge papers from Emergency Room and Urgent Care visits have been transferred to your provider
  • Call your provider first with medical problems, unless it is a medical emergency

Provider responsibilities

  • Listen to my patients' questions and concerns and give an appropriate response
  • Make the treatment and management plans for each patient's condition easy to understand
  • Make sure all my patients have a clear understanding of their treatment plan, all medications prescribed and goals
  • When needed, refer my patients to an appropriate specialist and/or local hospital
  • Make sure each patient receives medical care when the office is open, by providing Same Day Appointments and information about Urgent Care Centers when the office is closed
  • Provide disease specific educational materials to assist you in self-management