What is a patient-centered medical home? – Penn State Hershey Medical Center


The Patient Centered Medical Home has been
something that all the different societies of primary care got together and developed
this series of joint principals. And it’s really what we sort of think primary care
always should have been. Every person should have a personal physician, that their care
should be coordinated, that there should be access to the healthcare team, that the provider
should work part of a team, to really work together to meet the needs of the patient.
It’s really trying to have a more proactive healthcare approach. So really, right now,
most healthcare is reactive somebody comes in, their sick, they need some medicine, they
get treated and they go home and they come back next time their sick, it’s really an
acute care model. And what we’re talking about is something much more proactive. Strong
focus on preventative care, providers being able to understand that they have a population
of patients that their responsible for and so as opposed to only dealing with the patient
in the here and now when they see them during a visit, to be able to identify their population
and maybe call in patients that haven’t been seen for some time that need some help.
So that everybody get to be taken care of and the health of the whole population does
better. It’s having the practice work together as a team, where the nurses, front desk staff,
the doctor, their all working closely together to help the patient and really try to put
the patient at the center of the equation here and do everything that the patient needs
who ever that might be to help them. So yea, try to envision how things work, some
of these things are less obvious to the patient up front but I can give you a sense, so first
it’s a practice for example that is already worked out its work flow to be as efficient
as possible. That may not be obvious to the patient completely but it allows the practice
to have more time to do other things. The patient would be checking in and the person
checking in would know right away that they have diabetes, know that they were actually
planning on joining a gym last time they spoke with the providers or started a new medication
or some change that happened last time, I would just ask; how’s that going? And sort
of start the process. While that’s happening they get roomed and several of the things
that we know need to happen to improve care for example make sure you have a flu vaccine,
or if you are due for your ammonia vaccine, or have your feet checked whatever, the nurse
or medical assistant is already doing that for the patient before the doctor even gets
in the room. They’ve collected all the lavatory information, they ordered any labs the patient
needs based on some guidelines. Another sort of different approach in this
model is this idea of care management. So in any practice there are about five percent
of patients that are really sort of the most challenging that are really not doing well.
And the idea of the care manager is someone who it’s their job to take care of that
five percent. Because they need extra help, they got issues, they got problems, somebody’s
job it is to work with them. From the health system’s point of view, these are the most
costly patients to the system and so, putting a little extra resource more than pays for
itself. It will be most importantly better for patients,
they’ll be getting better care, more people will be getting their needs met. The other
piece that I didn’t mention but is an important part of this coordination of care and communication.
So, currently you know, a patient is seen here and they you know, go down a block and
see a doctor that’s not connected with the medical center. There is no flow of information.
The medical home is sort of, it’s the home, its where all of the information lies. The
primary care team knows everything that is going on, they have seen this specialist,
that specialist and the other specialist and they know if one specialist started, the medication
that doesn’t go with what the other one is doing. Because each specialist only sees
their little world. The home is the place where you can make sure there safe, that there
aren’t any drug interactions that doctor “A” didn’t know that doctor “B”
prescribed. You know, I think the reason payers in Pennsylvania has really taken the lead
here to support this initiative by changing reimbursement is that in the long run, you’re
going to save money doing this because people are going to be healthier and the healthier
people are the less expensive they are to take care of

1 thought on “What is a patient-centered medical home? – Penn State Hershey Medical Center

  1. Nice Vid, Thanks!

    Especially like the last quote that sums it all up "The healthier people are, the less expensive they are to take care of."

    Congrats on Penn State Hershey Medical Group being awarded the highest level of PCMH certification from NCQA

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