What Is a Medical Home?
The “patient-centered medical home” – an exciting new concept in primary care – is where health professionals work as a team to manage your care and head off potential problems. It’s especially important if you have a chronic disease such as diabetes that requires vigilant monitoring.
Empowering the patient is what it’s all about. Your doctor can prescribe medications, but if you’re not exercising, eating right and taking those drugs correctly, you won’t get your condition under control. This kind of attention takes time – much more than the typical 15-minute doctor appointment. Each patient is assigned to a care team that gets to know him well. As he needs it, he receives help with diet, quitting smoking, exercise and all the other components of good health management.
Your primary care provider is a key member of the medical home team, and many other health care professionals perform vital roles. Here are four examples of the medical home team in action across Lehigh Valley Health Network:
Medical records clerk, Lehigh Valley Physicians Practice, Allentown
My mother and I both have diabetes, and I know that without proper care, you can go blind. So when I learned many of our diabetes patients weren’t getting follow-up eye exams, I was happy to be part of a project to improve those numbers. We now put notes on patient charts identifying people who need eye exams. This lets our doctors immediately order an eye check for people who are overdue for one. With this new system, we’ve more than doubled the number of patients getting eye exams.
Certified medical assistant, LVPG Internal Medicine–1230 Cedar Crest, Salisbury Township
Patients from our practice don’t necessarily know what they’ll need after they are hospitalized. So I make sure they do – and that their needs are met. For example, some medications patients receive in the hospital may not be covered by their insurance once they are home. So I educate our patients about things like Medicare Part D, supplemental insurance or other ways to get their medication costs covered. I also talk with facilities like nursing homes and rehab hospitals to coordinate care if needed after a hospital visit. I educate patients on topics like diabetes, and will even help arrange transportation to doctors’ appointments for people who need it most. This helps our patients feel better at home and stay out of the hospital.
Triage nurse, LVPG Family Medicine–Laurys Station
If one of our patients needed a foot exam to prevent complications due to poor circulation, we took for granted that he went to a podiatrist on his own. But patients weren’t doing that. Some patients felt it was one too many doctors; others thought foot exams were embarrassing. So we made them more fun. My husband – a graphic artist – worked with me to create a big, colorful foot out of poster board. My colleagues copied the design and plastered the feet – festooned with jewels and toenail polish – along with the catchphrase “Expose Your Toes for Diabetes.” We put these posters in exam rooms. Now more than half of the patients who need a foot exam receive one in our office. We’ve also created other educational opportunities for people with diabetes.
Certified medical assistant, LVPG Internal Medicine–Muhlenberg
We want to make sure our patients know we are concerned about their health once they leave the hospital. So we call our patients 24 to 48 hours after they leave the hospital. We make sure they have all the medications they need and that their home and hospital medications are reconciled. We also make sure they have a follow-up appointment with their primary care doctor and a specialist, and arrange for devices like walkers if needed. In our office a nurse, medical assistant and doctor work as a team to deliver timely care. And when a patient comes back for a follow-up appointment, we’re familiar with the care she has received in the hospital.