Patient-Centered Medical Home

With your medical home, you will join a team that includes health care professionals, trusted friends or family members (if you wish), and—most importantly—you. A medical home is a practice that provides all your routine and preventive medical care and guides you through the system when you need specialty care or other services. They know you over time and work as a team from the receptionist to the doctor to provide your care. They use an electronic health record so they can access your information wherever they are taking care of you.

In the past medical care tended to be at the convenience of the doctor and the office staff. Office hours were based on the interests of the doctor, care plans were decided by the doctor and dictated to the patient to follow, and patients weren’t expected to ask questions or offer input. Patient-centered means services are provided at a time and in a way that is convenient for the patient when possible. That means such things as same day appointments, evening and weekend hours, electronic communication, and phone visits. It means involving the patient in the discussion of their problems, test results, options for treatment and plans so they can care for themselves. The medical team becomes a resource and guide for the patient, allowing patients to care for themselves.

Not only does the practice have an electronic health record to track patient’s care, but they communicate with patients electronically through email and Web pages and whatever else becomes available in the future. Patients can make appointments, check lab results and receive messages about their health care through electronic means instead of playing phone tag or waiting for the mail.

All of your personal care needs will be taken care of in a medical home but much of the emphasis will be on preventive care. At every visit consideration will be given to your immunization status, follow up of chronic conditions, and tests that may need to be done. There may also be nurses monitoring your chronic illnesses and scheduling you for visits or treatments as needed. There may be pharmacists who are monitoring your medications, possible interactions between medications, and follow up visits or tests that may be needed for those medicines. All of our practices use evidence-based guidelines to help make the best decisions about your health care.

It is your responsibility to communicate with your team of providers about changes in your medication, your health, and any symptoms that you may be having. You and your health care team will set goals for you that will help improve your health. You will need to talk about problems you are having in meeting these goals to improve your health. It is important that you understand what treatments are being recommended and that you have a discussion with your care team about those. Unlike old systems where the doctor told you what was going to happen without any discussion, it is now a joint decision. It is important that you ask questions and understand and agree with plans that are made. Once plans have been made, it is then your responsibility to comply with them or discuss with your provider if for some reason you are not complying.

• Be an active team player.
• Talk with your team about your health questions. Share the successes and the challenges you’ve had with health care in the past.
• Tell your team about other health care professionals who care for you.
•  Tell your team how you feel about the care you are getting from them.
• Take care of your health.
• Follow the health care plan you and your team have worked out. Make sure you understand how to follow the plan.
• Set goals you can reach. Once you begin to see results, you and your team can discuss adding new goals.
• Talk openly with your team.
• If you are having trouble sticking with your care plan, tell your team about it.
• If you feel your care plan is not working, speak up. Tell your team what is not working so together you can make changes if needed.

Community Health of Central Washington is taking part in a two year long patient- centered medical home collaborative. We are piloting several projects involved with medical homes and making corrections to processes until we find what works. We then expand those to the rest of our clinics.

Currently we have open access scheduling which means that you can get an appointment within a few days of calling. We also have two chronic care management nurses working at our site at Central Washington Family Medicine. They are piloting ways to help patients with chronic illnesses take better care of themselves. We have an electronic medical record although it does not have all the features we would like. We’re exploring other possible electronic health records that will aid us in meeting many of the goals of a patient-centered medical home.

We have systems in place to recall patients who need mammograms and Pap smears, but with a new electronic medical record we hope to increase the number of preventive services we are following. Although we are working on developing our webpage, we do not yet have a patient portal allowing two-way communication. We have plans in the future to develop e-mail communication capabilities with patients, but for security reasons that is not yet in place. We hope that all our providers are becoming more sensitive to involving patients in the development of their care plans and compliance with those plans. We welcome your feedback and suggestions and comments on how we are doing, other things that would make our practice more helpful to you, and meet your needs better.

• Make a list of your health questions. Ask a friend or relative for help if you need it. Put the questions that are most important to you at the top of the list.
• Make a list of other health care providers you have visited. Write down their names, addresses, phone numbers, and the reasons you visited them.
• Take all of your medicines, in their original containers, to your appointment. Be sure to include prescription, over-the-counter, natural, and herbal medicines and vitamins.
• Take your insurance card or other insurance information with you to your appointment.
• If you wish, ask a family member or trusted friend to go to your appointment with you.

During your appointment, use this handy checklist.

• Write down the names of your team members.
•  Use your list of questions. Ask your most important questions first. Even if you cannot get all of your answers on the first visit, having a list will help you keep track of the answers.
• Talk with your team about what health issue to work on first.
• Be sure you know what you should do before you leave the office.
• Use your own words to repeat back the things you’ve discussed with your team. This way, both you and your team will know the information is clear.
• Ask your team about how to reach them after hours if you need to.

Remember, the medical home can be a way for you to be informed about and involved in your health care decisions. The medical home can bring you, your family, and your health care team together to help you make the best choices about your health.

• Get to know your team. Your medical home team will know you and your family. They can help you manage your total health care. You can see the same team each time you visit, and they can help answer your health questions.
• Work with other medical experts if needed. For example, if you need to see a specialist, your team can keep in touch with the specialist to make sure you get the care you need.
• Track your health information using computers and electronic records. This way, your team will have all of your records in one place.
• Reach your team when you need them. Your team will have convenient office hours for your appointments.