Patient Centered Medical Home

We have recently started the journey to become a Patient Centered Medical Home (PCMH).  This may sound boring at first, but this an important change in the practice of medicine, so read on.  For those of you who haven’t heard the term “Patient Centered Medical Home” thrown around in the news, the PCMH is a theory of practice management that focuses on the clinic and the patient working as a unified health care team.  What the heck does that mean?  At its most basic, it means that both the patient and the doctors, nurses and staff work together to make sure a patient is receiving optimal health care.  Here’s how it breaks down:

  1. The health care team and the patient decide on goals and treatment plans together, identifying ideal care, but creating achievable goals for each patient
  2. Tracking patient data to a) make sure patients are getting timely follow-up on visits and lab work and b) monitor progression towards both patient goals and overall goals for each disease state for the clinic population.  For example, we would like all diabetics to get an eye exam every year, so we track this data and follow-up with patients to make sure they are getting their exams.
  3. Care is ideally coordinated across all care providers for a single patient.  This involves communication between all of a patient’s physicians, therapists, home health care providers (including family) and anyone else involved in their care. This is by far the most complicated aspect of providing comprehensive care for a patient.

Why are we doing this?  The whole purpose behind this approach is to provide comprehensive, goal driven, timely health care across the entire clinic population.  It is also to be proactive with health care, making sure patients are getting the recommended preventative care and that clinicians are following evidence based guidelines for delivering health care.   We are also doing this because it is the future of health care delivery.  It will soon be the expected model and insurances will be reimbursing physicians based on their quality of care.

As I mentioned above, this is a journey towards a PCMH.  We start with small steps by identifying immediate areas of concern, making small changes to our practices and moving forward step by step.  As we go, we incorporate disease states into our new model of care.  Of course, we continue to care for patients in the best manner possible, but as we add new diseases to this process, we become more proactive about their care.  There is no definitive end to the journey, because we never quit trying to improve our care.  However, we will be pursuing accreditation as a Patient Centered Medical Home through a governing body (NCQI).  Once accomplished, this will signify an important step in our continued effort to provide the best patient-centered and evidence-driven care around.

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