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Evolution of a Patient-Centered Medical Home

Carrie Vaughan, for HealthLeaders Media, February 10, 2011

Transformation of healthcare would result in a radical change in the patient-provider relationship. The patient would no longer be a passive recipient of care. The collaboration between the patient and the provider would be based on the rational accessing of care based on need, not desire.  

HL: How is the patient experience different today under this model? 

Holly: The patient experience has dramatically changed. For instance, the patient’s care is evaluated on the basis of more than 200 quality metrics; the patient receives a summary of these quality metrics with a recommendation to contact his or her healthcare provider to request that any metrics not completed be done and care transition points are attended to; and a “plan of care” and “treatment plan” baton is handed off to the patient so that they can participate effectively as the head of their healthcare team.

Because of SETMA’s department of care coordination, every patient who leaves the hospital receives a follow-up call the day after discharge. This is not a 15-second administrative call to fulfill a metric, but it is a 12–30 minute call, which has substance. Selected patients seen in the clinic receive follow-up calls at any interval determined by the healthcare provider related to vulnerabilities or complexities of their care.

In addition, both during the visit and in the treatment plan, a section is included which is entitled, “What If?” This section shows the patient how his or her risk will change if a number of individual elements or a combination of multiple elements used to calculate the risk is changed. 

HL: What steps did you take to ensure your providers and support staff were on board?

Holly: The first step we took in transforming our practice was an in-depth evaluation of our practice by the medical home standards published by CMS and NCQA. All of our executive management staff and providers were involved in this evaluation, which resulted in a 400-page review of our practice. The evaluation allowed all of our providers to see where we were, where we needed to go, and be part of the transformative process. 

We looked at the requirements for medical home and designed tools that made it easier to fulfill the requirements than not to fulfill them. We were able to transform our disease management tool follow-up documents into plans of care and treatment plans. 

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