Patient Centered Medical Home
Over the coming year, our practice will be transitioning to a patient centered medical home (PCMH) practice. Becoming a PCMH practice involves accreditation from the National Committee for Quality Assurance (NCQA), a non-profit organization that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation. This transition will greatly benefit the quality of care we deliver to our patients in the years to come. Please see below for more information regarding the specific features of the program.
The Medical Home is defined by the AAP as an approach to providing comprehensive primary care that facilitates partnerships between patients, clinicians, medical staff, and families. It is a medical practice organized to produce higher quality care and improved cost efficiency. This is facilitated by the following precepts:
The fundamental unit of the Medical Home is the relationship between the patient and the primary care physician (PCP). As a PCMH practice, every patient (and family) will select a PCP who will be fundamentally responsible for the care and management of that patient. The PCP's responsibilities will include seeing the patient for well checks as well as sick visits when available, managing chronic conditions, and arranging the patient's health care needs such as labs, referrals, and medications.
Continuity of Care
Ensuring smooth transitions between care episodes is of paramount importance to the medical home. In addition to visits at our office, we expect that patients will also receive care from emergency rooms, urgent cares, specialists' offices, etc. Our practice will be responsible for obtaining records of each episode of care, communicating with the treating physicians as necessary, and following up on appropriate recommendations. The PCP will always be informed of any outside care and will work with families to adjust the patient's care plan as needed.
One aspect of maintaining a medical home is ensuring appropriate follow up of every patient's treatment plan. When a provider orders labs, imaging, and referrals to specialists, the practice will track those episodes to confirm that the patient has obtained the appropriate test and/or scheduled with the appropriate specialist. Furthermore, we will verify that the results have been received and that the provider has taken the necessary action.
Many of our patients have increased health care needs due to complex medical conditions or complicated social situations. For these families, we will offer care management which involves the development of a care plan for the patient. The care plan is essentially a road map which directs the patient's care across all healthcare settings. The PCP will be responsible for updating the care plan, not only at office visits, but whenever we receive test results and updates from specialists. In this manner we can ensure comprehensive management of the patient, avoiding medical errors and duplication of efforts among the patient's care team.
A significant building block of the medical home is quality improvement (QI) which continuously monitors our medical practices and outcomes, and always strives to improve our care delivery. At any given time our office will be involved in several different QI projects that range from improving immunization rates in specific populations to tracking our asthma patients to improve their control scores. We also involve input from our families through the use of patient surveys and our suggestion box. Our practice always welcomes feedback and will try to make improvements accordingly.
Evidence Based Care
The cornerstone of quality medical practice is the delivery of evidence based care. A significant component of PCMH is the commitment to utilizing evidence based guidelines, which are provided by numerous medical associations including the AAP, CDC, and even our local Cincinnati Children's Hospital. In conjunction with clinical judgment and family input, these guidelines help to guide clinical decision making and determine when labs, imaging, and specialist referrals are necessary.
Access and Communication
Our providers and staff strive to be as transparent and accessible as possible for our patients. Patients have multiple ways to access care including direct communication by phone, email messages via our patient portal, and office visits. Patients have the ability to access most aspects of their medical record through the patient portal. Furthermore, our providers will always try to communicate the plan of care in a clear manner as well as to inform families of any test results in a timely fashion.