Patient Centered Medical Home
Most patients and their families have little understanding of how their primary care practice coordinates (if at all) with
other clinicians, organizations, and institutions in the neighborhood— and often may assume that the system is much more
coherent, organized, and coordinated than it is. One approach to decreasing fragmentation, improving coordination, and placing
greater emphasis on the needs of patients is the patient-centered medical home (PCMH). Its components include patient-centered
care with an orientation toward the whole person, comprehensive care, care coordinated across all the elements of the health
system, superb access to care, and a systems-based approach to quality and safety. Ultimately, these components are intended
to improve patient outcomes—including better patient experience with care, improved quality of care (leading to better health),
and reduced costs.
Specialists need to let primary care clinicians know what type of routine care the patient needs after a surgery or course of
treatment. Primary care clinicians need to make appropriate referrals and provide specialists with appropriate background
information, clinical data on the patient, and goals for the consultation. Hospitals need to let primary care teams know when
their patients are in the hospital or have visited the hospital’s emergency department (ED). In general, primary care clinicians
and other team members need a broad understanding of each patient’s health care needs to assist in coordinating all care, help
the patient navigate the system, and ensure that the treatment plans (and prescription medications) of different specialists work
together as a whole.
The medical home encompasses five functions and attributes:
1. Comprehensive 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.
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.
3. Coordinated Care
The patient centered 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.
4. Accessible Services
The patient centered 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.
5. Quality and Safety
The patient centered 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.
Of all the changes envisioned as part of the transformation to improved and more patient-centered primary care, perhaps none is more
promising and more challenging than the transition to team-based delivery of care.Team-based care is defined by the National Academy
of Medicine as "...the provision of health services to individuals, families, and/or their communities by at least two health providers
who work collaboratively with patients and their caregivers—to the extent preferred by each patient - to accomplish shared goals within
and across settings to achieve coordinated, high-quality care." Well-implemented team-based care has the potential to improve the
comprehensiveness, coordination, efficiency, effectiveness, and value of care, as well as the satisfaction of patients and providers.
At Premier Medical Associates PC , we strive to serve our patients better by incorporating the Medical Home concept of Team based care.
Substantial evidence points to a positive association between various aspects of patient experience, such as good communication between providers and patients, and several important health care processes and outcomes. These processes and outcomes include patient adherence to medical advice, better clinical outcomes, improved patient safety practices, and lower utilization of unnecessary health care services.
Our Care Team works diligently to improve patient experience and quality of care. We collaborate care for our patients with other Health care facilities in our community and guide them in navigating through healthcare systems and provide various community resources. We measure patient experience though effective patient surveys.
At PMA each of our patients is a part of their Care Team that include
The Clinician Lead – Ludy Lukose MD
The physician’s evolving role as a leader and facilitator of change is in line with the changing scope of medicine under the new Value based System. Thinking outside the examination room, the physician trains staff to practice in teams partnering with patients, to manage their care utilizing evidence-based medicine and incorporating population management.
The Midlevel Provider - Ellen Greer APRN
Playing an active role in diagnosing, establishing a care plan in the management of patients of various complexities, along with the Physician.
PMA PCMH Transformation Manager – Misty McConnell Healthcare Admin[AA], CMA
- Oversees the workflow of Office
- Assists/directs team members in achieving goals
- Identifying and providing needed resources/ training to staff and education to patients
- Determine timely access to care and maintaining efficiency of communication back to the Physician and the Midlevel Provider
- Works with Physician and Team members to identify and measure areas of Practice Improvement.
Patient Coordinator - Shelley Cavese CCMA
- First point of access to care, for the patients
- Schedules patients for appointments, preventive exams and diagnostic tests
- Identifies gaps in care and initiates action to close the gaps
- Works with Physician and Midlevel provider in identifying and communicating with patients in need of follow up
- Alerts the Physician and the Midlevel Provider of the ordered tests that need reconciliation and contacts patients
that may need communication regarding clinical care
- Attends to patient requests and messages on a daily basis and ensures proper communication with providers and back,
on their behalf
Clinical Coordinator - Amber Allen CCMA, Phlebotomist
- Triages patients and documents reason for visit
- Performs Comprehensive Health Assessment
- Administers medication/ injections/ immunizations at the direction of the Physician and the Midlevel Provider
- Reviews and reconciles medications with patient and family and assesses patient understanding of and adherence to medications
- Provides clinical advice and education to patients at the direction of the Physician and the Midlevel Provider
- Assists Physician and Midlevel Provider in medication refills and communication of test results to patients
Population Care Coordinator – Cynthia Sisson, CCMA
- Coordinates care with specialist offices
- Follows up on unreconciled ordered tests and referrals and reminds patients to have tests or referrals done
- Follows up with patients who were in the ED or admitted to hospitals and arranges follow up care with the
Physician or the Midlevel Provider
- Reviews patient charts and identifies gaps in care and communicates with patients to close those gaps
- Follows up with patients, in between office visits, to address their needs, continuously update their personalized
care plans and helps patients engage actively in their healthcare
Laboratory Services Coordinator – Desiree Salomon, CPT, CCMA
- Responsible for daily Lab services
- Reconciles Lab orders from the Physician and the Midlevel Provider
- Communicates with patients to address questions regarding billing for the Lab services
- Reminds patients of their Lab appointments
- Communicates with Outside Lab facilities in assisting patients get the results if pending/ overdue