Patient-Centered Medical Home

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Cleveland Clinic’s Medicine Institute was officially recognized as a patient-centered medical home in 2010. Medical homes exist at the Family Health Centers and on the Main campus; different models of team-based care were being piloted at three of the Clinic’s primary care locations, Strongsville, Independence and Main Campus Internal Medicine

Today, Cleveland Clinic is the first organization in the nation to achieve Primary Care Medical Home (PCMH) Certification for Hospitals from The Joint Commission.  This team based approach to care is now offered at 29 sites, which include 39 practices and 230 primary care physicians and advanced practice nurses.

Patient-centered medical home is a model of care where patients have a direct relationship with a provider who coordinates a cooperative team of healthcare, whether you’re being seen at the doctor’s office, if you become hospitalized or recuperating at home, through ongoing preventative care.

Your medical team will be invested in your care. The team always includes caregivers and the patient. Caregivers that may be included: Primary Care or Specialty Physicians, Community Based Providers, Nurse Practitioners, Physician Assistants, Medical Assistants, Registered Nurses, Care Coordinators, Pharmacists, etc.

In addition to your primary care physician, your team will also have a care coordinator. A care coordinator provides outreach and oversight of a patient and a patient population to ensure that preferences for care are understood, clinical goals are set, and appropriate interventions are implemented.

Managing medications can be challenging. That is why a pharmacist may be part of your team. Our pharmacists are clinically trained to help people manage chronic conditions such as high blood pressure, diabetes and congestive heart failure. They will work closely with your doctor and healthcare team to help you meet your treatment goals.

During a private consultation, your pharmacist will:

  • Address any concerns about medications (including cost, organizing pill boxes, side effects, and why medicine was prescribed)
  • Review any home test results, such as blood pressure or blood sugar
  • Show you how to refill prescriptions more easily
  • Make sure home monitoring devices are working properly and go over how to use them
  • Help you create a list of your medications and keep it up-to-date
  • Make a plan to deal with your concerns, such as working with your doctor to change your medication or order additional tests

Nurse practitioners (NPs) are advanced practice nurses who provide high-quality healthcare services similar to those of a doctor. NPs diagnose and treat a wide range of health problems. They have a unique approach and stress both care and cure. Besides clinical care, NPs focus on health promotion, disease prevention, health education and counseling. They help patients make wise health and lifestyle choices.

 

A patient-centered medical home might sound like a place, or somewhere you’d go. It’s not. It’s a long-term, team-based approach for your primary health care.

Patient-centered medical home is a model of care where patients have a direct relationship with a provider who coordinates a cooperative team of healthcare, whether you’re being seen at the doctor’s office, if you become hospitalized or recuperating at home, through ongoing preventative care.

We have created a “Patient-Centered Medical Home” in Internal Medicine and Family Medicine to enhance chronic disease management and prevention.

This team can lessen your primary physician’s load, so you’ll have more time to talk directly with your doctor about important issues like your medications, diet and any lifestyle changes you may need to make to control your blood pressure.

Because the team, too, is familiar with you and your history of hypertension, they can also address many of the concerns and questions you have about your condition.

Andrea Sikon, MD, Internal Medicine, Cleveland Clinic, says, “It increases continuity between patients and their doctors when possible and, when not, with a smaller group of practitioners — so we can strengthen face-to-face patient relationships.”

You’re in communication with a team that:

  • Focuses on the development of long-term doctor-patient relationships, rather than episodic care
  • Coordinates care among all of your providers within the team
  • Takes collective responsibility for your care
  • Arranges for appropriate care with other physicians, if necessary
  • If you’re hospitalized, once you’re discharged perform complete follow-up care to make sure your recovery is progressing

Your doctor will lead a team — which may include nurse practitioners, registered nurses, medical assistants or other caregivers — who will get to know you well. Together, they will take responsibility for your health. They will offer consistent, coordinated care and communication, and arrange for specialty care whenever you need it.

Benefits for you

  • You will see a familiar face at every appointment —a member of your caregiver team.
  • Your doctor and the other doctors on your team will be able to spend more quality time with you.
  • Your team may arrange a pharmacy consult for you to ensure that you understand how to take all of your medications.
  • If you are hospitalized at a Cleveland Clinic Hospital, your team will contact you within 48 hours of discharge to answer any questions. If you go to a hospital outside Cleveland Clinic, we ask you to notify them upon admission so they can contact your hospital team to coordinate care.
  • Once you are discharged, your team will ensure that your recovery is progressing as planned to keep you from going back in the hospital. They will also identify appropriate specialists you may need to see.

“ I, as a daughter of aging parents, play a large role in their health care.. My parents are patients with co-morbidities and such and have had many patient visits. We frequently discuss what is happening with their care so that I can be informed and support them when they need assistance or more information. Recently they noticed, as did I, some great new services. They have received some additional information about their conditions, wonderful follow-up, and direct phone contact discussing their conditions and test. This has made an impact not only on my parents but me too, it has helped to relieve some of the challenges that I encounter as a caregiver for my family.”

66 year old female with diabetes for over 10 years. Blood glucose levels were not in control. Repeated visits to the local emergency department and her doctor’s office with the primary care physician and nurse practitioner, aided in the patient’s compliance. The care coordinator was in constant contact with the patient to aid in managing medications and blood glucose levels. Female patient raves about her "team of ladies" who helped stabilize her blood glucose levels.

Coordination of care is also enhanced when patients sign up for MyChart. MyChart: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients to portions of their personalized health information, allowing them to:

  • Review past appointments
  • Manage your prescription renewals
  • Manage appointment requests and cancellations
  • View your health summary, current list of medications and test results as released by your physician
  • Receive important health reminders
  • Access reliable health information about a broad range of topics of personal interest

To learn more and sign up if you have not already, please visit our MyChart Online Services.

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