PCMH Ambulatory Care

Overview of the Patient Centered Medical Home project piloted by Geisinger Health System in Danville, Pennsylvania

Patient-centered medical home (PCMH) is a way to transform primary care practices into medical homes that coordinate care and communicate to what patients want to maximize health outcomes. Medical homes may lead to lower costs, higher quality care, improve patient experience of care, allow better access to health care and improve health.

The author has been employed in the healthcare field for over fifteen years that has allowed the time to observe the transformation of the primary care practice. This paper will examine the industry using Aspirus, Inc. as the reference point; however encompassing an examination of other healthcare institutions. Evidence suggests the Patient Centered Medical Home (PCHM) model, also known as the medical come, of care can offer many benefits, including improved quality in the patient experience and disease management and lower costs to the patient and system because of reduced emergency room visits or hospital admissions. The main objective of this paper is to highlight the challenges and explore what the PCMH model will be like in five years within the primary care setting of a healthcare organization.

On February 2, 2016, the Patient-Centered Primary Care Collaborative (PCPCC) report highlighted 30 primary care PCMH initiatives that measured cost and utilization of services and concluded that PCMH reduces costs and improves health care quality. A senior vice president at the Blue Cross Blue Shield Association mentions that reduction in hospital admissions, emergency room visits and health care costs and

Introduction Health disparities exist across socioeconomic classes, races, and genders, among other characteristics. Often, social determinants of health are cross-sectional in that one typically affects another. Regardless of location, an ethnic majority is more likely to receive the benefits of quality care whereas the minority in that same area is likely to have unequal access to the quality of care that they, as humans, are entitled to have. Disparities between two ethnic groups stem from sociocultural as well as biological factors. In the United States, differences between Native American populations and their white American counterparts are not unknown to the average American.

Health Status of Minority Group Medical advances and new technologies have provided people in America with the potential for longer, healthier lives more than ever before. However, persistent and well-documented health disparities exist between different racial and ethnic populations and health equity remains elusive. Health disparities — differences in health outcomes that

Throughout history, the health care system of the United States has always had some form of disparities. These disparities are a major concern in today's health care system, especially since equality is held as the highest standard in our society. But in order to understand how health disparities can be brought to a halt, an understanding of the determinants of health is needed. Health of individuals and populations is determined by many factors such as, health services, race and ethnicity, socioeconomic status, environment, geography, legislative policies, genetics, etc. Solutions to these problems have been the

Critical advanced planning and analysis of a practice capabilities are important to achieve financial success and improved patient outcomes in a PCMH model.

Eloisa- all medical issues of the patient should be significant to providers. “One main goal is to allow physician-patient relationships to grow in order to coordinate quality care”. Yes, quality care is all about having great communication and understanding what is needed to provided quality care. Everyone can strive to improve their health/medical being. As you stated, “PCMH allows “practice improvement strategies,” in which,

The patient-centered medical home model is a framework developed by the Agency for Healthcare Research and Quality aimed at improving and transforming how primary care is organized and delivered. The patient-centered medical home model has five core functions: Comprehensive Care, Patient-Centered, Coordinated Care, Accessible Services and Quality and Safety. Comprehensive Care involves the utilization of a diverse team of care (physicians, nurses, nurse practitioners, therapists, pharmacists, community health workers, social workers, case managers, educators, nutritionists, etc.) in order to meet all of the patients health care needs including physical and mental health, prevention and wellness, acute care and chronic care. Patient-Centered Care recognizes the importance of the patient in their care and developing a partnership with the patient when developing care plans. Coordinated Care emphasizes the need for coordination of services and communication among different service providers during the transition of care. Accessible services focuses on timely and responsiveness to patients by reducing waiting times and implementing telehealth communication. Finally, Quality and Safety refers to the commitment of quality improvement through the use of evidence-based medicine and clinical decision-support tools15. All aspects of the patient-centered medical

Access to health is the determinant factor of the health disparities. “In the United States disparities are well documented in minority populations such as African Americans, Native Americans, Asian Americans and Hispanics, all of which constitute twenty eight percent of the population (McHenry, G.).” Ethnic disparities, indicators include social justice, economic realities, shifting census, and disease burden. Latinos tend to have low access to care and language barriers effecting both access and quality care. Studies show that

The medical homes are defined as models of care that include personal physicians, whole person orientation, coordinated and integrated care, and evidence-based medicine (American Nurses Association, 2010, as cited by Haas, 2011, p.11). This is an area that will benefit the chronically ill patient such as diabetes, hypertension, to mention a few. This type of patients will benefit from such program.

Managing and improving health outcomes for such people are enhanced through a HHS MCC Strategic Framework. One of the primary goals of the framework is to provide better information towards healthcare and persons who deliver quality care to persons suffering from multiple chronic conditions (U.S. Department of Health & Human Services, 2010). As provided in the U.S. Department of Health & Human Services (2010), the primary objectives for directing chronic condition management in the U.S. are as follows: to foster healthcare and public health system changes in order to improve the health conditions of individuals with MCC; provide for better tools and information to the public health, the healthcare, and also to the social services personnel to ensure effective delivery care for said individuals; to maximize the use of proven self-care management and other services by these individuals; and to facilitate research to resolve knowledge gaps as regards interventions and

The Institute of Medicine (IOM) defines patient-centered care as: “Providing care that is respectful of and responsive to individual patient preference, needs, and ensuring that patient values guide all clinical decisions (1). Patient centered care is also one of the overreaching goals of health advocacy, in addition to safer medical systems, and greater patient involvement in health care delivery and design. Patient-centered care is also about empowering patients by giving the right weight to their opinions about the health care system. Overall home care can be represented through the following diagram;

For example, primary care reduces hospitalizations, emergency department (ED) visits, and inappropriate or unnecessary specialty consultations (http://www.aafp.org/news/practice-professional-issues/20150805califprimcare.html). Second, an accessible, well-functioning primary care “home” or Patient Centered Medical Home (PCMH) can improve patients’ satisfaction with received care. Lastly, it has the potential to lessen absenteeism and low productivity in the workplace from chronic disease associations in patients. It also produces better patient outcomes as well since primary care is the site in which most chronic conditions are treated (http://www.commonwealthfund.org/~/media/files/publications/health-reform-and-you/health-reform_primary-care_612.pdf). Lower productivity and absenteeism contribute to costs by means of less economic production which lowers tax revenues and hurts businesses and government