Patient Centered Medical Home: a Coordinated Health Care System


November 25, 2013 

I thought I would take this opportunity to tell you about one of modern health care's most important innovations, the “Medical Home” or Patient-Centered Medical Home (PCMH). The Medical Home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety.

Why is the Medical Home important? First and foremost, patients are treated with respect, dignity and compassion, which begins to establish a strong bond with providers and staff.

The PCMH model builds on substantial evidence demonstrating that greater emphasis on primary care can result in higher quality at lower costs. This model encourages the patient to visit their primary care provider when they are well, enabling the provider to keep the patient healthy through preventative care. Prevention of chronic diseases through early intervention is the key to healthier communities, thereby lowering the overall health care costs.

To accomplish this, a core team of health care professionals consisting of providers, case managers, nurses and reception staff work together to coordinate a patient’s care. Care coordination improves quality, appropriateness, timeliness and efficiency of clinical decisions and care. The PCMH provides primary health care that is relationship-based with the whole person at the center. Partnering with each patient and their families requires understanding and respecting each patient's unique needs, culture, values and preferences. The team actively supports patients in learning to manage and organize their own care and healing process, at whatever level they choose. 

With a PCMH, the traditional doctor's office is transformed into a central hub to organize and coordinate a patient's health care, based on the patient’s needs and priorities. Patients receive reminders about appointments and their health team reviews patients’ histories to make sure appropriate screenings and tests are performed. The team is there to support not only the patients with chronic conditions, but also their families. The care is coordinated across all elements of the broader health care system, including specialty care, hospitalizations, home health care, end of life services, and community services.

With more of our community members having access to care through the upcoming Accountable Care Act, and with the shortage of primary care physicians (especially in rural areas like ours), team-based care coordination is a valuable tool. This will help physicians meet the demand of seeing more patients while remaining confident that each individual patient’s needs, both chronic and preventative, are being met.

In a new health care environment that could be managed by a Health Maintenance Organization (HMO), primary care is the center of care decision making. By definition, an HMO is an organization that provides health care to people who make regular payments and agree to use only the doctors, hospitals, and specialists contracted within the specific HMO. Especially in this context, an HMO is only financially sustainable when the first component is the team that makes up primary care. This "gatekeeping" function will diminish unnecessary emergency room visits and readmissions to hospitals, while decreasing costly diagnostic testing and saving you money.  

~Lin Hunter, CEO



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