Family Medicine and Primary Care
Patient-Centered Medical Home
As a Physician Practice Connection®-Patient-Centered Medical Home™, we seek to strengthen the physician-patient relationship by replacing episodic care based upon illness with a comprehensive, coordinated care approach. Our goal is to develop and maintain a long-term healing relationship with each of our patients. We share information to support you as a proactive participant in your health and wellness.
The Patient-Centered Medical Home (PCMH) model emphasizes a patient’s relationship with one doctor. The doctor, leading a team at a single location, takes collective responsibility for the patient’s care in an effort to provide the patient with more personalized, coordinated, effective and efficient care.
Health and wellness partnership
With your involvement and our communication, your medical home team will work to provide you personalized care that supports your total health and well-being.
Patient-Centered Medical Home has the potential to improve patient health by improving patient access to comprehensive primary care services. This can result in higher patient satisfaction with care and increased health and wellness benefits.
NCQA is a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations. It also recognizes clinicians and practices in key areas of performance. NCQA is committed to providing health care quality information for consumers, purchasers, health care providers and researchers.
Whole person care
You are the center of your care team. By engaging as an active member in managing your own health, you will have a greater understanding of your healthcare needs. We encourage you to:
- Let us know about any care received outside the medical home
- Keep your appointments and arrive on time
- Follow the care plan provided by your physician
- Participate in activities to improve your health
- Provide us with feedback about your health and wellness, and ask questions of your care team
We also support your health and keep you informed by providing:
- Same-day scheduling and urgent care
- MyChart – a secure online portal to view your medical information
- Nutrition classes and other patient education resources
- My Care Management – a program focused on patients with chronic conditions requiring ongoing care
To learn more about any of these services offered, please ask any member of your care team.
Managing chronic conditions
For our patients with chronic conditions that require ongoing care, we offer My Care Management, a program to help you manage your health through a care plan designed just for you. Your care manager will work with your primary care physician to coordinate the best possible patient care. The care manager's role includes:
- Contacting you between office visits to help you meet your treatment goals.
- Communicating with your physician and other healthcare providers.
- Providing educational resources and opportunities to assist you in managing your condition.
- Identifying opportunities for dietary one-on-one counseling or group classes.
Continuity across healthcare settings
As your medical home, we are here to ensure the continuity of your healthcare. In the event emergency or specialty services are required, it is important to contact us as soon as possible. We work with you and the other members of your healthcare team to schedule the appropriate follow-up care with your physician.
We also encourage you to call on us to schedule your preventive appointments.
Medical home care team
As your care team, we are focused on your wellness by taking a proactive approach.
- We provide timely access to your care providers.
- We reach out to you to schedule necessary appointments including preventive screenings and exams.
- We follow best medical practices to ensure you receive the highest quality care.
- We ensure you understand your health conditions and provide educational tools to help you manage your health.
- We listen to your needs, set healthcare goals and ask for your feedback.
- We coordinate your care across care settings. For example, we ensure necessary labs or tests are scheduled, and results are complete, prior to your visit.
- We work with other healthcare specialists you may visit to co-manage your care.
This team-based approach ensures the continuity of your care.