What is a Patient Centered Medical Home?
Joint Principles of the Patient Centered Medical Home
What are the changes and additional benefits that I will get as a patient in a Patient Centered Medical Home?
How do I learn more about the Patient-Centered Medical Home?
Background of the Medical Home Concept
Opt-Out
Patient Tools
Activity and Exercise Log Sheet
Atlantic General Health System’s network of primary care providers has been accepted to participate in two Patient Centered Medical Home programs. Our providers at Townsend Medical Center in Ocean City and in our Berlin Primary Care office on Old Ocean City Boulevard will be participating in the Maryland Multi-Payer Program for Patient Centered Medical Homes. Our providers in Ocean Pines, Snow Hill, Pocomoke City, Selbyville, DE and Ocean View, DE have been accepted into the Maryland CareFirst Patient Centered Medical Home program.
So what is a Patient Centered Medical Home?
The Patient Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth and adults. The PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.
Click here for a video about PCMH.
Joint Principles of the Patient Centered Medical Home
Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Quality and safety are hallmarks of the medical home:
• Practices advocate 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 physicians, patients, and the patient’s family.
• Evidence-based medicine and clinical decision-support tools guide decision making
• Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
• Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
• Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
• Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
• Patients and families participate in quality improvement activities at the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.
Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
• It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
• It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
• It should support adoption and use of health information technology for quality improvement;
• It should support provision of enhanced communication access such as secure e-mail and telephone consultation;
• It should recognize the value of physician work associated with remote monitoring of clinical data using technology.
• It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
• It should recognize case mix differences in the patient population being treated within the practice.
• It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
• It should allow for additional payments for achieving measurable and continuous quality improvements.
What are the changes and additional benefits that I will get as a patient in a Patient Centered Medical Home?
Team Based Care:
• Your Primary Care Provider will lead a team of nurses and support staff to work with you to meet all of your health care needs.
Better Health Care Access and Communication:
• During normal office hours
-We will make every effort to see you on the same day you call if you have an urgent health care need. You should call your provider’s office number during working hours to schedule a same-day appointment with us. Many urgent health care needs, including cuts, earaches, colds and fevers can be handled by your
Patient Centered Medical Home team. If for any reason we are unable to see you on the same day we will refer you to the next appropriate level of care.
• After normal office hours
-If you have an urgent medical issue when your provider’s office is closed, call the office telephone number and follow the instructions given to reach the on-call provider.
•
Please continue to call 911 for all emergencies.
• Your
Patient Centered Medical Home Team will be monitoring your medical needs and will contact you to schedule follow-up appointments.
• Your
Patient Centered Medical Home Team will help coordinate your specialty appointments. We will help you in making sure that all tests, procedures, and specialist appointments are scheduled in a way that best meets your health care needs. We ask that patients inform us if they are seen by any other providers or visit the emergency room for any reason.
• Working together, we can understand your health risks, if any, and take care of them before they become more serious problems.
• In order for us to provide our best primary care services, please let our Medical Home Team know if you see any other health care provider. Also, please remind any health care provider that you may see to forward reports to us regarding your condition and treatment. This will allow us to best coordinate your clinical care.
How do I learn more about the Patient-Centered Medical Home?
• The following websites provide more detailed information about the Patient Centered Medical Home and its benefits to patients.
o
http://mhcc.maryland.gov/pcmh/
o
http://pcpcc.net/consumers-and-patients
Background of the Medical Home Concept
The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, initially referring to a central location for archiving a child’s medical record. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.
The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have since developed their own models for improving patient care called the “medical home” (AAFP, 2004) or “advanced medical home” (ACP, 2006).
OPT-OUT
all active patients are automatically enrolled in the Patient Centered Medical Home Program. However, you can opt out by filling out the opt-out form. Please select the appropriate form below. Completed forms may be returned to your health care provider's office.
Craig Johnson PA-C
Dr. Deborah Conran
Dr. Donmoyer
Dr. Tran
Dr. Waters