Health Matters: Having a Patient-Centered Medical Home Promotes Quality Health Care

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Above: Team Based Care at MCHC Health Centers

January 2017

MCHC Health Centers is dedicated to providing access to health care for everyone in our communities, and the best way we’ve found to do so is through the Patient Centered Medical Home (PCMH) model.

This is a team-based approach that allows us to operate like a health care hub: patients come to us first, no matter what their health care complaint may be, and we either provide the care directly or we coordinate the care through referrals. This approach prevents duplication of care and eliminates unnecessary tests—and it allows us to understand all the health care issues influencing a patient’s condition.

I was at a conference recently where one of the presenters joked about how his mother, a retiree living in Florida, glows in the dark because of the repetitive radiological tests she’s been exposed to—no one was coordinating her care. With care coordination, you get the single diagnostic or laboratory test you need, and those results are shared with anyone in your medical team who needs to see them. This saves you time and money, and keeps you safe by minimizing your exposure to radiation.

At MCHC, we do this with a care team made up of nurses, providers, case managers and medical assistants, who all work together with the patient to reach the patient’s health goals. Truly, the most important member of the team is the patient because patients are in the best position to know what is realistic for them and what treatments will work best for them.

The ultimate goal of our PCMH model is to provide safe, effective, patient-oriented, timely, efficient and equitable care. To measure whether we’re succeeding and to find ways to improve how we deliver care, our Quality Improvement (QI) Department analyzes large volumes of data. Based on our findings, the QI department introduces new initiatives; this includes integrating behavioral health and oral health into the PCMH model.

With the introduction of Electronic Medical Records (EMR) a number of years ago, we are now able to track numerous indicators. Using standardized quality measures, we are able to streamline our organization reporting and this also allows us to compare ourselves with other clinics. We share many of these indicators with our providers and their care teams, with our patients in our waiting rooms, with MCHC Board members, and with the federal agencies who monitor and fund health care.

The PCMH model is linked to the “Triple Aim” framework, which was developed by the Institute for Healthcare Improvement (IHI). It describes how to optimize health system performance and incorporates the following goals: 1. Improving the patient experience of care (including quality and satisfaction); 2. Improving the health of populations, and 3. Reducing the per capita cost of health care.

We strive to have quality permeate through our entire organization, in part by helping our staff genuinely feel that quality is an integral component of everybody’s job description. This involves our whole organization and is not confined to the clinical component.

There are many factors that go into making someone healthy. In fact, I’d say access to medical care only accounts for a small percentage of someone’s overall health. The social determinants of health play a greater role in how healthy a person is, determinants like their economic status, including housing, nutrition, education, access to transport and cultural practices, which can influence gender roles and belief systems. This is why the patient must be at the center of his or her care team. Working together, the health care professionals and the patient can overcome barriers, so the patient can take care of their health as well as possible.

 

Prior to his work at MCHC, Dr. Jaisingh Niemer worked in Africa as a health care adviser who assisted local governments in setting up health care quality programs. He received his master’s degree in Public Health from Harvard University and now serves as the director of Quality Improvement at MCHC Health Centers, a local, non-profit, federally qualified health center offering medical, dental and behavioral health care to people in Lake and Mendocino Counties.

 

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