All Northern Counties Health Care, Inc. (NCHC) Health Centers are nationally accredited Level 3 (the highest level) Patient Centered Medical Homes (PCMH) by the National Committee for Quality Assurance (NCQA).
The PCMH, or “medical home” model is an approach to providing comprehensive and quality primary care for children, youth and adults that facilitates partnerships between patients, their physicians, and when appropriate, their families. It also means we are constantly striving to improve our quality and delivery by working with patient care teams to track and coordinate care, and fully utilize technology such as electronic health records.
The medical home encompasses five functions and attributes:
- Comprehensive CareThe primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. Your team might include physicians, advanced practice nurses, physician assistants, nurses, behavioral health professionals, pharmacists, nutritionists, social workers, educators, and care coordinators.
- Patient-CenteredThe primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing care plans.
- Coordinated CareThe primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.
- Accessible ServicesThe primary care medical home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients’ preferences regarding access.
- Quality and SafetyThe primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management.
Watch a video from the American Academy of Family Physicians about Patient Centered Medical Homes. (Please note, the link to this video will direct you away from NCHC’s website to YouTube.)
And while we’re talking about data, check out how our sites have been doing with Screening Patients Age 65 and Older for Future Falls Risk:
Reason for Screening: As the leading cause of both fatal and nonfatal injuries for older adults, falls are one of the most common and significant health issues facing people aged 65 years or older. Moreover, the rate of falls increases with age. Older adults are five times more likely to be hospitalized for fall-related injuries than any other cause-related injury. It is estimated that one in every three adults over 65 will fall each year. In those over age 80, the rate of falls increases to fifty percent. Falls are also associated with substantial cost and resource use, approaching $30,000 per fall hospitalization. Identifying at-risk patients is the most important part of management, as applying preventive measures in this vulnerable population can have a profound effect on public health. Family physicians have a pivotal role in screening older patients for risk of falls, and applying preventive strategies for patients at risk.
Click to enlarge.