What is a patient-centered medical home? - Penn State Hershey Medical Center

Uploaded by PennStateHershey on 31.07.2012

The Patient Centered Medical Home has been something that all the different societies
of primary care got together and developed this series of joint principals. And it’s
really what we sort of think primary care always should have been. Every person should
have a personal physician, that their care should be coordinated, that there should be
access to the healthcare team, that the provider should work part of a team, to really work
together to meet the needs of the patient. It’s really trying to have a more proactive
healthcare approach. So really, right now, most healthcare is reactive somebody comes
in, their sick, they need some medicine, they get treated and they go home and they come
back next time their sick, it’s really an acute care model. And what we’re talking
about is something much more proactive. Strong focus on preventative care, providers being
able to understand that they have a population of patients that their responsible for and
so as opposed to only dealing with the patient in the here and now when they see them during
a visit, to be able to identify their population and maybe call in patients that haven’t
been seen for some time that need some help. So that everybody get to be taken care of
and the health of the whole population does better. It’s having the practice work together
as a team, where the nurses, front desk staff, the doctor, their all working closely together
to help the patient and really try to put the patient at the center of the equation
here and do everything that the patient needs who ever that might be to help them.
So yea, try to envision how things work, some of these things are less obvious to the patient
up front but I can give you a sense, so first it’s a practice for example that is already
worked out its work flow to be as efficient as possible. That may not be obvious to the
patient completely but it allows the practice to have more time to do other things. The
patient would be checking in and the person checking in would know right away that they
have diabetes, know that they were actually planning on joining a gym last time they spoke
with the providers or started a new medication or some change that happened last time, I
would just ask; how’s that going? And sort of start the process. While that’s happening
they get roomed and several of the things that we know need to happen to improve care
for example make sure you have a flu vaccine, or if you are due for your ammonia vaccine,
or have your feet checked whatever, the nurse or medical assistant is already doing that
for the patient before the doctor even gets in the room. They’ve collected all the lavatory
information, they ordered any labs the patient needs based on some guidelines.
Another sort of different approach in this model is this idea of care management. So
in any practice there are about five percent of patients that are really sort of the most
challenging that are really not doing well. And the idea of the care manager is someone
who it’s their job to take care of that five percent. Because they need extra help,
they got issues, they got problems, somebody’s job it is to work with them. From the health
system’s point of view, these are the most costly patients to the system and so, putting
a little extra resource more than pays for itself.
It will be most importantly better for patients, they’ll be getting better care, more people
will be getting their needs met. The other piece that I didn’t mention but is an important
part of this coordination of care and communication. So, currently you know, a patient is seen
here and they you know, go down a block and see a doctor that’s not connected with the
medical center. There is no flow of information. The medical home is sort of, it’s the home,
its where all of the information lies. The primary care team knows everything that is
going on, they have seen this specialist, that specialist and the other specialist and
they know if one specialist started, the medication that doesn’t go with what the other one
is doing. Because each specialist only sees their little world. The home is the place
where you can make sure there safe, that there aren’t any drug interactions that doctor
“A” didn’t know that doctor “B” prescribed. You know, I think the reason payers
in Pennsylvania has really taken the lead here to support this initiative by changing
reimbursement is that in the long run, you’re going to save money doing this because people
are going to be healthier and the healthier people are the less expensive they are to
take care of