A man with diabetes has stopped checking his blood sugar levels. The device he uses to monitor his condition is 10 years old and doesn’t work anymore, but he can’t afford a new one.
Meanwhile, a woman goes to her primary care physician complaining of fatigue and unexplained weight gain. Her physician orders blood tests. But a week later, when she sees a specialist recommended by a friend, the specialist unknowingly orders the exact same tests.
Stories like these are all too common. But what if the man received a prescription for a low-cost glucose meter and met with a diabetes educator to help him learn more about monitoring his condition? What if the woman’s primary care physician communicated regularly with the specialist who had access to all the test results?
That’s what can happen when patients find a "patient-centered medical home," or PCMH. It sounds like a place, but it's actually a team.
"The patient-centered medical home is a model that creates a patient-physician partnership allowing for improved, more personal health care," explains Andrew Cykiert, D.O., President of the Botsford Hospital medical staff and Director of Continuing Medical Education. "The 'home' is led by your primary care physician, who will coordinate your health care needs in a team approach."
Dr. Cykiert's practice in Livonia, Midwest Internal Medicine Associates, has the PCMH designation by Blue Cross/Blue Shield of Michigan. Like other PCMH practices, a physician is on call around the clock. Same-day appointments are available and care coordinators follow up with patients and help answer their questions.
Michelle Bartle, R.N., is the care coordinator for Botsford Primary Care in Dearborn Heights. "I am a resource for the patient. I am a name, a face and a phone number. Patients know there is someone in the office responsible for getting things done for them," she says. "In a medical home, the team works together and communicates regularly. Care is more consistent and more efficient. This leads to better outcomes."
Patient visits are preplanned. "Before you come in, your chart has been reviewed. Your test results are are already here," Bartle says. "This way you can focus on your relationship with your doctor."
Under the direction of your primary care doctor, the medical home team may include a number of players, including specialists, dietitians, social workers and pharmacists. On this team, patients are more than just benchwarmers.
"Patient education and self-management is a big part of the medical home. We want to get patients involved in their own care," says Bartle. "It’s not just high-risk patients. Preventive medicine is also an important part of the medical home."
New electronic medical records help with coordination of care. "We can better track patients who fall through the cracks and monitor how often patients are undergoing tests," notes Bartle. "If we don’t see patients in a while, we can send reminders."
Patients will receive a summary of their care plan after each visit, detailing what follow-up is required, what medications they are on and any other steps that are needed, such as physician referrals or tests. Soon, they will also access their medical history, schedule appointments and communicate with their doctors online.
"We are utilizing technology, focusing on better communications and going back to the team approach," says Bartle. "This way, we work more efficiently to keep our patients healthier."
Practices designated PCMH: