Patient-Centered Medical Home

We are pleased to inform you that we are a Patient-Centered Medical Home, which is a primary care medical practice that fosters a rewarding, trusting partnership between a doctor-led healthcare team and an informed patient.

At no additional cost to you, this practice will enhance its services to improve your health care experience. You will notice some changes. For example, there will be better access for urgent appointments, more focus on preventive care, and more emphasis on communication and coordination of care. Your role as a patient will change, too: We want you to become more involved in your own care. Let us describe the benefits our new approach will provide to you.


What is a Patient-Centered Medical Home and Why Now?

The foundation of the Patient-Centered Medical Home is a team-based approach that improves your access to care and allows us to do a better job planning and coordinating it with you. Using tools and team work, we can provide care when you’re sick and when you’re well - before, during, after, and between appointments. The Patient Centered Medical Home is not a place or a fad but a model of care. It was first described in 1969, but did not really take off until recent years, when technologic advances, like electronic medical records, patient portals, and even cell phones, came about to support a tighter bond between hospitals, doctors, practices, and the patients themselves. Additionally, healthcare reform, which focuses on higher quality and lower costs, has brought even more attention to the value of the Patient Centered Medical Home. Practices that operate like this one tend to have higher patient and doctor satisfaction scores as well as provide better value for our nation’s health care dollars.


What are the Changes and Additional Benefits that I Can Anticipate?

Team-Based Care

Your doctor is still YOUR doctor: the quarterback of your care. That will not change. You will notice your doctor is better-equipped to coordinate your care because of enhanced communication with others who provide care to you: for example, specialists, the emergency room, hospital-based physicians and even the familiar folks here who answer the phone, check your blood pressure, and ask about your kids. Think of your Medical Home Team as all of those who help take care of you at this practice: doctors, physician assistants, nurse practitioners, nurses, medical assistants, and support staff. You are part of the team, too.

Improved Access

  • Let us be your urgent care center! When we’re open for business, your doctor can usually see you the same day that you have an urgent need. Or, if that is not possible or convenient for you, one of the practice’s Medical Home Team members (another doctor, a physician assistant, or a nurse practitioner) will see you. We recommend you call the office number during regular office hours to schedule a same-day appointment with us. Many urgent needs, including lacerations, can be handled at the practice. See below for our contact information and hours of operation. We are working to be open for you at more convenient times.
  • Call coverage, 24/7. If an urgent care issue arises outside of our practice’s hours of operation, call our telephone number and follow the instructions that you will be given to reach the on-call provider. You will get the advice you need to take care of your concern. Of course, continue to call 911 for all emergencies.
  • Access to your medical record is available 24/7, anywhere. For general medical advice about non-urgent matters, you can contact us electronically at any time (24/7) through MyChart, our secure patient portal, even viacell phone. You can also use MyChart to check your medical records, review results, request a refill, and more. .

Improved Communication Leads to Better Care Coordination and Better Health

  • Health maintenance and management of chronic conditions: Your Medical Home Team will monitor your medical needs and contact you to schedule follow-up appointments if they are not already arranged.
  • Visits with specialists: Your Medical Home Team can help coordinate appropriate specialty visits, special procedures and testing. We can advocate for you and make sure you get the right care at the right time.
  • Two-way communication is best: We ask that you inform us if you are seen by any other providers or visit the emergency room for any reason – so that we will be better prepared to take care of you.
  • Making a plan: Talk with your doctor about developing a personal care plan, especially if you are coping with a chronic condition like diabetes, heart failure, or depression. A personalized care plan can provide a path to help you obtain the best possible health outcomes, including steps you can take outside of your visits with us to improve your quality of life and meet your goals. This works even for prevention and health maintenance. Working together, we can understand your potential health risks and address them before they become chronic problems.


You are Part of the Team.

That means we trust you, our patient, to:

  • Tell us what you know about your health and illnesses, including family history
  • Tell us about your needs and concerns
  • Take part in planning your care
  • Follow the care plan that is agreed upon, or let us know why you cannot so that we can try to help or change the plan
  • Tell us what medications you are taking, and be responsible for obtaining refills
  • Let us know when you see other doctors and what medications they put you on or change
  • Ask other health providers to send us a report about your care when you see them
  • Learn about your insurance so you know what it covers
  • Respect us as individuals and as partners in your care
  • Keep your appointments as scheduled, or call and let us know when you cannot
  • Pay your share of the visit fee when you are seen in the office
  • Give us feedback so we can improve our services

As we build your Medical Home, we will continue to:

  • Provide you with your own doctor who knows you and your family
  • Respect you as an individual and as a partner in your care
  • Respect your privacy; your medical information is protected by law
  • Provide care given by a team of people led by your doctor
  • Coordinate your care with other medical professionals outside the practice
  • Give the care you need when you need it
  • Give the care that meets your needs and fits with your goals and values
  • Give care that meets current quality and safety standards in primary care
  • Have a doctor on call for telephone advice 24 hours a day, 7 days a week
  • Take care of both brief illnesses and chronic health conditions, and give advice to help you stay healthy
  • Tell you about your health and illness in a way that you can understand

You may notice that:

  • We ask you what your goal is, or what you want to do to improve your health
  • We ask you to help us plan your care, and let us know if you think you can follow the plan
  • We give you a written copy of the care plan and expect you to provide us with periodic reports of your progress at home
  • The team care members are doing more and/or different parts of your care. We remind you when tests, visits, and health maintenance items are due
  • We ask you to sign up for MyChart so that you can play a more active role in managing your care
  • We are using more enhanced technology to improve the care you receive

We are excited to be able to provide you with this opportunity and are confident that you will be pleased with our Patient Centered Medical Home approach. We look forward to partnering with you in this endeavor.