We often talk about our patients when they aren’t around. We discuss their diabetes goals for example. Patients with diabetes need to achieve five goals to reduce their risk for complications and every patient is likely to have different motivations for reaching those goals.
At regular staff meetings, my team of caregivers will create action plans to improve the care that we give to our diabetic patients using what we know about what motivates them. Do they want to spend more time with grandchildren, write the great American novel or travel? What steps can they take now to improve or maintain their health and make those dreams real?
This is what we call a Patient Centered Medical Home (PCMH) model of care. I explain to model to my patients like this:
- My staff and I as your primary care physician work hard to know you and coordinate your care
- We make sure that you get the right care at the right time, without unnecessary duplication of services and without medical errors
- For example, at our practice we make referrals for you to see a specialist when you need one and we make sure that specialist has the information he or she needs to ensure you transition in care is smooth and coordinated
- We track and support you when you obtain services outside our practice
- We follow-up with you within a few days of an emergency room visit or hospital discharge
- We communicate test results and care plans to you and your family
- We link you with community resources that might benefit you
- We provide you with a nurse care coordinator who is a point person that works with you and your family on a regular basis and is always available to answer questions even when I may not be
When you are part of a PCMH, there is always a health care professional available to talk with you, 24 hours a day/7 days a week.
PCMH practices use quality measures such as those found at YourHealthMatters.org as a tool in their quality improvement efforts. You can picture YourHealthMatters.org as a scorecard for entire clinical teams, not just physicians, grading the team’s ability to provide you with quality healthcare and good outcomes. Knowledge is power and YourHealthMatters.org helps us know where we need to improve. The “WE” is you, your doctor and our entire team, because a strong patient-health care team partnership means we do our part and you as a patient need to do yours.
Here\’s the story of one of our patients, John M., a friendly 48-year-old. He has been struggling with controlling his diabetes mellitus for several years. He struggles with his busy lifestyle, demands at work, and financial constraints that prevent him from affording all of his medications. When John joined our practice, we started to work with him using our PCMH strategy to not only help him control his diabetes, but also to help him to make positive changes on his own that would lead to better glucose control.
By working with our care coordinator in the office, he was able to become more consistent with monitoring of his sugars. We used resources to help John have access to medications that he was previously unable to afford. John worked with us to set realistic goals to incorporate diet, exercise and monitoring of his blood sugars into his busy lifestyle. Happily, John has seen a significant improvement in his blood sugars, feels better and continues to stay motivated to control his health.
PCMHs are gaining in popularity as we transform health care in the United States. In fact, under this new model, our pay is tied to the quality of care we offer you and the outcomes you as a patient achieve working together with us to reach your health goals. We look forward to partnering with you, our patients!
Brian Peerless, MD
Mercy Health – Blue Ash Family Medicine