How Patient-Centered Medical Homes Are Transforming Care
August 8, 2013 | Jacksonville, FL
Patient-Centered Medical Homes are rapidly gaining momentum across the country. Baptist Primary Care has been in the forefront in North Florida for obtaining accreditation for this innovative model of care that leverages teamwork and technology to provide high-quality care that is personalized, coordinated, convenient and focused on a long-term healing relationship.
Currently, 24 of Baptist Primary Care’s 44 office locations have achieved Level 3 Patient-Centered Medical Home Accreditation from the National Committee for Quality Assurance, and many more offices are expected to join their ranks in the coming months.
Adam Dimitrov, MD, is a Family Medicine physician at Baptist Primary Care Ponte Vedra Beach and chair of Baptist Health’s Patient- Centered Medical Home Task Force. He explains some of the ways that the Patient-Centered Medical Home model has transformed the way his office cares for patients.Better Transitions in Care for Hospitalized Patients
Evidence shows that hospitalized patients are less likely to be readmitted if they receive a follow-up phone call within 48 hours of discharge and are seen by their primary care physician within two weeks. Many employees throughout Baptist have been working together to make this happen for Baptist Primary
Care patients who are discharged from any of our hospitals. Dr. Dimitrov explains, “We have developed a system where the nurse navigators at the hospitals are contacting the Baptist Primary Care doctor using the electronic medical record to let them know when one of their patients is being discharged. Then, either the nurse navigator at the hospital or the medical assistant at the doctor’s office calls the patients within 48 hours to make a follow-up appointment.”Easier Access for Patients with Urgent Needs
Baptist Primary Care practices that are accredited as medical homes are committed to having same- day appointments available for their patients with urgent needs, whether it’s with a primary care physician, a physician assistant or a nurse practitioner.
"Our practices are often very busy with the demand for care. That being said, when people are ill, they wish to be seen by those healthcare providers who know them best. This leads to better satisfaction and quality of care. Our practices are working hard to accommodate those patients rather than asking them to go to urgent care centers or the emergency room. We feel it’s the right thing to do.
“We feel strongly that every patient should have a medical home with a primary care doctor who serves as the quarterback of their medical team and works with you to manage your health,” says Dr. Dimitrov. Better Tracking of Preventive Care
Car dealerships are great about letting you know when you are due for your next oil change, but health care, largely due to its complexity, has lagged behind when it comes to reminding patients about preventive care. Baptist’s Patient-Centered Medical Homes are now using the electronic medical record to track patients’ care, not only to send out reminders, but also to check on follow-up.
“Now, any time we order a test like a colonoscopy for a patient, we track that to see if we received the results. If we haven’t, then we can contact the patient to find out if there is something we can do to help them in the process.” A Teamwork Approach
“We feel strongly that every patient should have a medical home with a primary care doctor who serves as the quarterback of their medical team and works with you to manage your health,” says Dr. Dimitrov. “Part of what this means is that our staff practices to the limits of their licenses. Our medical assistants do more than check vital signs. They are very engaged in the patient’s care. For example, they can be trained to complete a diabetic foot check if the patient needs one.” Sharing Resources
Being a part of Baptist Health also means having access to resources that will benefit the patient and allow Baptist Primary Care offices to operate more efficiently.
“Most practices don’t have the ability to hire a care coordinator, diabetes educator, dietitian and pharmacist, so we are looking at how we can share some of these resources that the hospitals have for our patients,” he says. “We are running a pilot project with some of the diabetes educators. The AgeWell Center for Senior Health is another example of utilizing shared resources for our geriatric patients.”