Patient Centered Medical Home

Patient Centered Medical Home

Policy Title: Patient Centered Medical Home / Original Date: 5/2014
Reviewed Date(s): 9/2014 / Revised Date(s): / Next Review Date:9/2016
Attachment, Forms and/or Manuals:

POLICY STATEMENT: Kansas City CARE Clinic is committed to providing each primary care patient comprehensive, patient-centered, coordinated, and accessible high quality care. Our practice is designed as a Patient Centered Medical Home (PCMH) and all staff and volunteers are important members of the patient care team. The patient is a partner in a successful Patient Centered Medical Home practice and every effort is made to engage the patient in that partnership.

AUTHORITY/ACCOUNTABILITY: The Clinical Practice Committee owns this policy. Medical Affairs committee is the approval authority for this policy.

DEFINITIONS None

PURPOSE: This policy is intended to provide the framework for the design of our practice as a Patient Centered Medical Home.

PROCEDURE:

Comprehensive Care

The Clinic is responsible for meeting the patient’s physical and mental health needs, providing preventive and wellness services, and providing acute and chronic care for our patients. The Clinic makes every effort to obtain a complete medical history and collect information about medical care outside of the Clinic to facilitate proper care. Dependent upon the patient’s payer source and the network of providers within each payer source these services may be provided on site by our multidisciplinary team of physicians, nurse practitioners, nurses, case managers, community health workers, behavioral health, social services, and oral health providers or through referrals to our community partner network of providers.

Patient-Centered Care

The foundation of our practice is the provision of primary health care focused on the whole person and their unique needs. We recognize the impact of culture, values, family relationships, health literacy and patient choice on each patient’s health status. We recognize that the patient’s health status is a partnership between the patient and our practice and work to ensure that the patient is fully informed in order to be a core member of their health care team.

Coordinated Care

The Clinic coordinates the care patient’s receive within the broader health care community including specialty care, hospitals, home health and other community services. Transitions of care between those services and our primary care practice are coordinated by selected staff in order to ensure seamless delivery of care.

Accessible Services

Patient access to clinic services and clinical advice and consultation when services are not available is an important aspect of their primary care. The Clinic offers many avenues for access to advice and consultation from which patients may choose. The Clinic maintains hours of operations that are conducive to patient access including evening and Saturday hours. The clinic maintains a nurse advice line which is operational during clinic hours and provides 24/7 telephone access to nurse advice and provider consultation. A patient portal is available for access to the patient’s medical record and nurse advice.

Educating Patient on the Patient-Centered Medical Home

The Clinic has a process for informing and educating patients regarding the patient-centered medical home model though various channels. Each new patient receives a brochure outlining the PCMH approach, responsibilities of providers and patients, and benefits. These brochures remain available at the front desk and in exam rooms. Information is also available on the Clinic’s website. Most importantly, patient-centered care at the Clinic is guided by patient interactions with clinical and non-clinical staff. Staff responsibilities include:

Staff asks patients to provide complete medical history, which is recorded in EHR.
At each visit, staff asks about care received elsewhere such as ER, urgent care center, other provider, etc. to be fully informed and coordinate care across multiple settings.
Staff advises patients to call the Clinic’s On-Call Nurse Line for clinical advice when the office is closed.
Staff members receive regular training on evidence-based care, to provide patient with the best possible treatment and support.

Quality and Safety

Evidence based practice guidelines are incorporated into all aspects of our practice. Care protocols, practices and standing orders are based on these. Clinical decision support tools are incorporated into our electronic health record to assist providers at the point of care. The Clinic has a robust quality improvement process which provides on-going performance measurement of clinical indicators, patient satisfaction, and population health. Results from the quality improvement process inform the design and implementation of performance improvement projects and are shared with funders, regulators, and the Clinic’s consumer advisory board.

MONITORING:The Practice Manager in collaboration with the Medical Affairs committee is responsible to assure that all aspects of the practice promote a patient centered medical home approach.

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