By Tom Herman, LPN, Medical Home Care Coordinator

Visiting the doctor can be confusing, scary and just one more thing to put on your already busy schedule. For those in our community suffering from chronic conditions and/or mental illness managing appointments and understanding care instructions is even more challenging.

A newer medical care model – the Patient Centered Medical Home (PCMH) – is one way that organizations are trying to transform how primary care is organized and delivered for patients. A PCMH model has 5 main characteristics: comprehensive care, patient-centered, coordinated care, accessible services, and quality and safety. This model is accountable for meeting the majority of each patient’s physical and mental health needs and includes prevention and wellness, acute care, and chronic care through a team of care providers that may include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educations and care coordinators. The care is relationship-based with a focus on the whole person, and is coordinated with specialty care, hospitals, home health, and community supports. The team demonstrates a commitment to quality by engaging evidence-based medicine, patient satisfaction, and population health management.

United Family Medicine is a certified PCMH, and began using this model in 2011. UFM engages a team approach to help coordinate care, and these teams are assisted by Medical Home Care Coordinators. Using a plan of care developed by the patient and their provider, the Medical Home Care Coordinator coordinates services. This allows the patient, with the provider’s input, to design a personal plan to address medical issues that are important to the patient and their family. It is the job of the Medical Home Care Coordinator to assist the patient in the coordination of care and to ensure the patient receives the care they need, when and where they need it.

This is a team approach to primary health care. The patient and their family work closely with the provider to form a partnership to improve health outcomes and quality of life for individuals with chronic health conditions. When a patient decides to become involved in Medical Home Care Coordination they are agreeing to focus on aspects of their health that require attention. They actively participate in the design of their care plan and the interventions needed to achieve their health care goals. The patient’s engagement in the care plan of action and their desire to improve their health are the two most important aspects of Medical Home Care Coordination.

The aim of Care Coordination is to strengthen the provider/patient relationship by replacing episodic care with coordinated care, pre-visit planning, and a long-term holistic approach. Medical Home Care Coordination allows patients a direct contact to their provider. The relationship that develops between the Care Coordinator and the patient allows for continuity of care, the addressing of issues important to the patient and their families, and it assists the provider and patient by offering a structured plan. Being proactive with our healthcare will hopefully allow us to avoid acute episodes of ill health.

It is the intent of United Family Medicine to become our patients “Health Care Home”. We hope to offer a place to come to when your health require attention. With a comprehensive plan of action in place, our patients and their families can feel comfortable knowing their goals are being addressed.

No one likes to visit their doctor. Most everyone would prefer leading a healthy life, free from sickness. By partnering with you to address your health care needs head on, and in a proactive way, we hope our patients will feel better and will lead happy and active lives for as long as possible.

United Family Medicine

United Family Medicine