Patient-Centered Medical Home (PCMH)

The PCMH Model is a framework of care that places the patient at the center of care and emphasizes care coordination and communication.
PCMH is an accredited care standard that focuses on care coordination, access to care, and effective primary care manager (PCM) and team work in partnership with the patient and their family. We focus on education and self-management by the patient and with the patient. We track and coordinate your care and use health information technology to support your care. The PCMH Team consists of the PCM, the Team RN, the LPN or 68W Medic, the Medical Support Assistant, the Nurse Case Manager, Integrated Behvioral Health Consultants, Clinical Pharmacists, and Dietitian.

The PCMH Model of Care focuses on these core functions:

1. Patient-Centered Care: Relationship-based care focused on the whole person and understanding and respecting each patient’s unique needs, culture, values and preferences. The practice actively supports the patients in learning to manage and organize their own care at the level they choose. We recognize family members are core members of the care team and are included in establishing goals and care plans.
2. Comprehensive Care: A team of providers who work to meet each patient’s physical and mental health care needs, including prevention and wellness, acute and chronic care.
3. Coordinated Care: Care is coordinated across the healthcare spectrum to include specialty care, hospitals, homecare and community services and support.
4. Access to Care: Our goal is that patients have shorter wait times for urgent needs, enhanced in-person hours, around the clock telephone or electronic access to the team. Our standards are:
   1. Acute/Urgent Need: Seen within 24 hours
   2. Routine Need: Seen within 7 days
   3. Specialty Care: Seen within 28 days
   4. Wellness Need: Seen within 28 days
   5. Emergency Care: If you require emergency care, go to your nearest emergency room or call 9-1-1.
5. Systems-based approach to quality and safety: We use evidence-based medicine and clinical decision tools to engage in process improvement and performance measurement. We respond to patient experience and satisfaction feedback. We practice population health management and share quality and safety data and improvement activities.