Defining a PCMH – and the advantages for patients

The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the Agency for Healthcare Research and Quality (AHRQ) defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

A patient centered medical home model provides benefits for both patients and caregivers. Patients gain more one-on-one time with their physicians and have access to a team of providers that can include nurse health educators, optometrists, podiatrists, pharmacists, nutritionists, dentists and mental health counselors – all in one place. What’s more, these providers work together to ensure that each patient receives the care they need to maximize their overall health and well being. And when a patient needs specialty or hospital-based care, our health center has built strong relationships with multi-specialty practices and community hospitals to which they can refer patients, all the while tracking their progress and treatment regimens.

The medical home encompasses five functions and attributes:

Comprehensive Care
The primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities.

Patient-Centered
The primary care medical home provides health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing care plans.

Coordinated Care
The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.

Accessible Services
The primary care medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients’ preferences regarding access.

Quality and Safety
The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

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  • Providers involved include:

    URGENT CARE
    Monica Francis, PA

    PEDIATRICS
    Avi Silber, MD, FAAP
    Tracy Lucas, FNP
    Adeola Ayodeji, MD, FAAP

    INTERNAL MEDICINE
    Chanchal Singh, MD
    Sneha Shrivastava, MD
    Penelope Guccione, FNP

    WOMEN’S HEALTH
    Julie A. O’Connor, CM, LM, MS
    Marian Seliquini, CM, LM, MS

    FAMILY MEDICINE
    Koreen E. Thomas, FNP
    Andrea Giovinazzo, FNP-C

    URGENT CARE
    Kate Michalak L.Ac., RPAC

    DENTAL
    Alban Burke, DDS

    OPTOMETRY
    Neha Dada, O.D.

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