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What is a Medical Home?

From Cheshire Medical Center Dartmouth-Hitchcock Keene

In a healthcare world that has become sophisticated and complex, the important role of primary care physicians is sometimes overlooked. As America’s baby boomers reach their 50’s and 60’s, as new medications and technologies allow people to live longer, and as poor lifestyle choices contribute to chronic diseases, the need for primary care medical providers has become increasingly important. Unfortunately the number of primary care physicians is declining.

Cheshire Medical Center / Dartmouth-Hitchcock Keene (CMC/DHK) is working diligently to become the healthiest community in the nation by the year 2020 (Vision 2020). To attain such a lofty goal will require a strong coordinated effort by a broad representation of our community, increased knowledge and personal responsibility on behalf of individuals and families, as well as a system and process of medical care that supports population based health improvement. The role of the primary care physician and other primary care providers becomes vital to our shared success. At CMC/DHK we are convinced the primary care medical model of choice is Medical Home, sometimes referred to as Patient-Centered Medical Home.

What is a Medical Home?
Medical Home is a model of care that promotes close partnerships and coordination of care between individual patients, other health providers and physicians. Rather than treating patients as the sum of several episodic office visits, with the Medical Home model a patient’s care is administered by a physician-led team that provides for the patient’s health needs and coordinates treatment across the healthcare system. Medical Home physicians demonstrate the benchmarks of patient-centered care that include open scheduling, expanded access, the appropriate use of proven health information systems, and the addition of care coordinators to the healthcare team. It is anticipated this model of care will improve health and health care. The Journal of the American Medical Association notes, “The concept of a patient–centered medical home is gaining traction in debates about expanding access, improving quality and restraining the cost of health care. These homes include physician–led multidisciplinary teams that provide comprehensive primary care… integrated, evidence-based quality measurement, better communication for the patient experience and modern health information technology.”

The partnership between patients, mid level providers and doctors in a medical home fosters an all-too-rare goal in modern medical care; staying healthy and preventing illness in the first place. In a Medical Home, a great deal of emphasis is put on wellness, prevention, health screenings, and other strategies that allow people to take a greater responsibility for maintaining their health. The Medical Home team takes a proactive approach to working with patients to achieve the best possible health outcomes.

Medical Home is here
Cheshire Medical Center/ Dartmouth-Hitchcock Keene has taken the lead in NH and within the Dartmouth-Hitchcock system to bring the Medical Home model to its primary care practices in Keene. Recently CMC/DHK received recognition from the Physician Practice Connections (PPC)-Patient Centered Medical Home program for its use of “evidence-based, patient-centered techniques that focus on highly coordinated care and long term participative relationships.” This recognition, awarded by the National Committee for Quality Assurance, is based on PPC standards reflecting input from the American College of Physicians and others, which assess whether physician practices are truly functioning as medical homes.

What do the doctors say?
Medical Home is not only a good idea for patients and their families, physicians embrace it as well. Andrew Tremblay, MD a Family Medicine specialist and primary care doctor at Dartmouth-Hitchcock Keene has the distinction of being a practicing physician in Keene as well as growing up and attending school in Keene. Dr. Tremblay says of Medical Home “We are very excited about the concept of Medical Home. It allows us to deliver the highest quality of care using the most current evidence-based aspects of medicine, and most importantly, it allows us to do this in a personal and patient-centric manner that brings Primary Care back to its grass roots.”

Family physician and Family Medicine Department Chair, Leslie Pitts, MD is also a strong proponent of Medical Home and has been intimately involved in its planning and implementation at CMC/DHK. Notes Dr. Pitts, “At a time when medicine is becoming increasingly complex and expensive, the need for listening, coordinating patient concerns or test results, or just offering practical medical advice is greater than ever. The Medical Home model is a new way to deliver primary health care. Together the care team is uniquely positioned to handle most basic medical needs and concerns, to help coordinate specialty care, and connect with health resources in our community. We believe this model will allow us to sustain primary care practice in Cheshire County so as to continue providing our patients with continuing high quality and high reliability care.“
Care Coordinators
One of the unique hallmarks of Medical Home is the use of Care Coordinators.

Care Coordinators are registered nurses who are integral members of the Medical Home team. Care Coordinators work closely with physicians and patients to help navigate the system, assist with specialty referrals and proactively assist with different aspect of care. For example, if a diabetic patient hasn’t had important lab tests performed recently, or needs to follow up with other doctors to monitor the possible side effects associated with diabetes, care coordinators takes the lead in coordinating appointments, scheduling laboratory, assisting with referrals, tests and procedures. The information gained and the recommendations of other physician specialists become part of the communicated treatment plan coordinated by the physician-led Medical Home team.

Widely acknowledged as a vehicle for providing high quality medical care that proactively engages patients and their providers in a model of health that is coordinated and proactive, Medical Home is coming of age. CMC/ DHK continues to be a leader in New Hampshire and beyond, offering innovative health solutions that will help realize its shared goal of becoming the healthiest community in America. Read more…