The Health Gazette : The Patient-Centered Medical Home Care Model

The Patient-Centered Medical Home Care Model

What is a Patient-Centered Medical Home (PCMH)?

A PCMH is a care delivery model that utilizes technology in conjunction with a medical team to improve patient satisfaction and quality of care while reducing medical costs. The medical team is comprised of physicians, ARNPs, PAs, nurses, counselors and case managers to ensure patients understand and receive the appropriate care.

Evidence-based medicine and clinical decision-support tools guide decision making. The patient is at the center of the medical team and actively participates in decisions concerning their health. To ensure patients’ expectations are being met in regards to their care, feedback is sought and physicians accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.

How is care facilitated differently with this model?

The PCMH model streamlines patient care through improved communication between the patient and their healthcare providers. Care is facilitated by information technology, health information exchange between providers, and other means to ensure that patients get the indicated care not only when and where they need, but when they want it in a culturally and linguistically appropriate manner.

The medical team advocates for their patients to support the attainment of optimal patient care, performance measurement, patient education, and enhanced communication not only through traditional means such as in-person communication but through online secure vehicles such as the patient portal. The patient can utilize the portal to communicate with their healthcare team, request appointments, view test results and access their medical chart to review, print or email. Patients will also receive a summary of each office visit and may receive appropriate educational material related to any medical problem(s) or concerns.

Communication is also improved between the patient’s providers (TPCA and non-TPCA providers). Care is coordinated and/or integrated across all elements of the complex health care system (e.g., sub-specialty care, hospitals, home health agencies, nursing homes, etc.) and the patient’s community (e.g., family, caregivers, public and private community-based services, etc.).

How can medical costs be reduced with PCMH?

By putting the patient at the center of the medical team and providing them with the tools needed to succeed, a more preventive approach is taken. Reducing medical costs can be accomplished by increasing utilization of preventive medicine services, keeping patients healthier as per the old Benjamin Franklin adage “an ounce of prevention is worth a pound of cure.”

Besides preventive services, does TPCA offer additional assistance to patients with existing chronic conditions?

We are proud to offer a chronic care management team that targets patients who have multiple chronic conditions. The team closely follows these patients to make sure they utilize the appropriate resources. We also have transitional care management which follows a patient closely after discharge from the hospital to reduce recurrences of their illness which may help reduce hospitalizations.

The medical team advocates for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between providers, patients, and patient families/caregivers.