Visiting the doctor can be confusing, scary and just one more thing to put on your already busy schedule. For those in our community suffering from chronic conditions and/or mental illness, managing appointments and understanding care instructions is even more challenging.

A newer medical care model — the Patient Centered Medical Home (PCMH) — is one way that organizations are trying to transform how primary care is organized and delivered for patients. A PCMH model has five main characteristics: comprehensive care, patient-centered, coordinated care, accessible services, and quality and safety. This model is accountable for meeting the majority of each patient’s physical and mental health needs and includes prevention and wellness, acute care,

and chronic care through a team of care providers that may include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators and care coordinators. The care is relationship-based with
a focus on the whole person, and is coordinated with specialty care, hospitals, home health, and community supports. The team demonstrates a commitment to quality by engaging evidence-based medicine, patient satisfaction, and population health management.

United Family Medicine is a certified PCMH, and began using this model in 2011. This is a team approach to primary health care. The patient and their family work closely with the provider to form a partnership to improve health outcomes and quality of life for individuals with chronic health conditions.

When a patient decides to become involved in Medical Home Care Coordination, they agree to focus

on aspects of their health that require attention. They actively participate in the design of their care plan and the interventions needed to achieve their health care goals. The patient’s engagement in the care plan of action and their desire to improve their health are the two most important aspects of Medical Home Care Coordination.

The aim of Care Coordination is to strengthen the provider/patient relationship by replacing episodic care with coordinated care, pre-visit planning, and
a long-term holistic approach. Medical Home Care Coordination allows patients a direct contact to their provider. The relationship that develops between the Care Coordinator and the patient allows for continuity of care, the addressing of issues important to the patient and their families, and it assists the provider and patient by offering a structured plan. Being proactive with our healthcare will hopefully allow us to avoid acute episodes of ill health.

No one likes to visit their doctor. Most everyone would prefer leading a healthy life, free from sickness. By partnering with patients to address their health care needs head on, and in a proactive way, we hope they will feel better and will lead happy and active lives for as long as possible.


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