CEO Corner: Patient Centered Medical Home 

The Patient-Centered Medical Home (PCMH) model is an alternative approach to the delivery of primary care services that focuses on improving both patient experience and clinical results. While PCMH was introduced a decade ago, it is becoming a growing trend nationally due to identified gaps in the delivery of primary care services and the rising cost of health care.

Key principles of a PCMH model include access to care that is based on an ongoing relationship with a personal clinician and a team of professionals with the goal of integrating care across the health care system. Fundamental to the PCMH model is the use of a robust Electronic Medical Record (EMR), and an infrastructure that includes care managers and coordinators to ensure that patients receive the care they need across all providers (i.e., primary care, specialists, hospitals, home health services, pharmacists).

The Health Center’s approach to the PCMH model includes innovative efforts to improve the patient experience. GLFHC has had an EMR since 1999, and has been very successful in producing patient data that has helped improve care delivery and treatment of chronic disease. GLFHC is adept at providing care coordination across the continuum of care, and links patients to chronic disease management programming, social intervention through the Community Support Services Department, pharmacy and medication education, as well as mammography and other diagnostic screenings that are designed to reduce health disparities in our patient population. As such, being part of practice redesign and payment reform relating to patient-centered care is a natural choice for us and for our strategic direction.

The Health Center has been participating in a pilot PCMH program for the last few years, and recently secured a contract with the state of Massachusetts to continue implementing this model, which demonstrates well-coordinated services and enhanced access to a clinical team. Expected outcomes include improved clinical quality, improved patient experience, and reduced health system costs.

GLFHC is committed to the provision of staff and other resources to support this project. In addition to the staff dedicated specifically to the PCMH Practice Teams, other Health Center departments and programs will contribute to the effective operation and integration of the PCMH model. As described in The Changing Face of Nursing, our nursing staff plays an important role in the PCMH model. They offer a holistic, patient and family-centeredness approach to care, by often assuming a patient advocacy function in the care coordination process.