PCMH is a way of organizing primary care that emphasizes
care coordination and includes the patient as a part of the team. “In addition
to leading to higher quality care and lower costs, a PCMH cultivates more
engaging patient relationships,” explained Michele McMorris, Medical Practices
Director at Jones Memorial Hospital. “A better patient experience leads to
better health outcomes.”
At a PCMH-certified practice, a care manager or social
worker is available to help coordinate patients on their care and ensure a
smooth transition from one level of care to another – like going from the
hospital to home. “Care managers and social workers provide education and
arrange for additional support and resources that the patient may need,” Mrs.
McMorris added. “They look at the patient’s record and follow up on
preventative care and tests ordered by the provider, reminding the patient when
they have not been completed.”
Each of the primary and pediatric practices have regular
huddles to discuss individual patient care. “It is a team approach – the
provider, the nurse, the receptionist the care manager and the social worker –
coordinate to come up with a plan for each patient before the next
appointment.”
In order to maintain PCMH status, the medical practices will
continue to identify opportunities to better manage patients.
