Patient-Centered Medical Home

As your Patient-Centered Medical Home, HSI provides great communication throughout your treatment. The provider team communicates with each other and with patients at all stages of care, equipping patients with the information needed to be an active team member in their health care.

What is a Patient-Centered Medical Home or PCMH?

The patient-centered medical home is also referred to as the primary care medical home (PCMH) because it is an approach to primary care that is completely different than the traditional way it has been delivered and organized.

Why PCMH?

The Patient-Centered Medical Home is the basic premise that the patient is at the center of care, receiving a full range of comprehensive services provided by a team of health professionals including social worker, nurse and pharmacist, in addition to the primary care provider. Health care teams work together, on the best course of action, to provide patients with the recommended preventive care, chronic disease management, as well as acute care needed to obtain successful outcomes.

They’re able to do this with the help of robust information technology like electronic medical records which allows each team member to know whose condition is under control, what the most up-to-date recommendations are for treating a certain condition, and how they are performing as a provider team.

This model has been our practice for years. Why? Because the data shows that, in medical homes, patients get better quality of care, they’re more satisfied with their care, and they get this for lower overall health care spending.

Defining the PCMH

The following comes from the Agency for Healthcare Quality and Research (AHRQ). The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, the AHRQ defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care.

Your Patient-Centered Medical Home encompasses five functions and attributes:

Comprehensive Care

The primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic 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. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities.

Patient-Centered

The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. 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.

Coordinated Care

The primary care 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. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.

Accessible Services

The primary care 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. The medical home practice is responsive to patients’ preferences regarding access.

Quality and Safety

The primary care 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. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

As your Patient-Centered Medical Home, HSI provides great communication throughout your treatment. The provider team communicates with each other and with patients at all stages of care, equipping patients with the information needed to be an active team member in their health care.