Too many patients use the emergency room for primary care. Too many people have different doctors who don’t talk to each other. Too many chronically ill patients slip through the cracks of our healthcare system.
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There are ways to fix these problems. One of them is the Patient-Centered Medical Home (PCMH). The PCMH is not a new idea, but it’s catching on as our focus shifts to value-based care because of healthcare reform. The entire model is based around better care and lower costs, specifically for people with chronic conditions or recent hospitalizations.
Think of it like a football team, where every medical professional has a position to play. They win by working to keep you healthy.
The quarterback for your care
In the PCMH model, your primary care physician (PCP) is the quarterback of a care team.
The idea: Your PCP knows your personal case inside and out. In fact, this doctor likely manages a group of patients who share your condition: heart disease or diabetes, for example. In addition, your PCP will hand off important logistical work to a “care coordinator,” usually a nurse.
If you skip an appointment, your care coordinator follows up to make sure you’re not missing a critical screening or treatment. If your prescriptions need adjusting, your PCP will adjust them. If you could benefit from a clinical trial or new therapy, your PCP will help you register. Most important, they both keep your electronic health record up to date so everyone on your team has the latest details of your case.
The team players
In a PCMH model, team members come from any and all disciplines with a focus on your condition.
For example, if you have diabetes, your team might include:
- A primary care physician for ongoing care.
- A nurse who serves as care coordinator.
- An endocrinologist for specialty treatment.
- A medical assistant who does much more than just take vital signs.
- A registered dietitian for advice on diet and nutrition.
- A fitness expert focused on keeping you physically fit.
- A clinical pharmacist with a deep understanding of diabetes medications.
If you’re wondering how that’s different from today, the answer is coordination. Right now you may get referrals, but you often will have to seek out these individuals on your own. In a PCMH, they’re all in one place.
In football, preparation happens off the field as much as on it. In the PCMH model, care happens outside the office as much as in it.
Taking advantage of new technology is important. Sometimes a simple e-mail, e-consult or phone call will suffice instead of a costly office visit. Activities such as physical therapy may begin to happen in your home using two-way video technology. And wellness education can be delivered digitally, with the goals of starting healthy habits and limiting how often you need in-person care.
If this sounds too good to be true, keep in mind some aspects of the PCMH mode are already working. Home care programs for heart disease have reduced hospital readmissions and emergency care, for example.
The PCMH, when done properly, will give you a home for your healthcare — and a home team.