Patient Centered Medical Home

The Patient Centered Medical Home model is designed to provide primary health care that is relationship-based, with the whole-person concept in mind. PCMH is an accredited care standard that focuses on access to care, effective primary care manager (PCM) and teamwork in partnership with the patient and their family, education, and self-management by the patient and with the patient. Additionally, this model’s focus is to provide quality accessible health care by a team of professionals who know and understand your family’s unique needs.

Your PCMH team can include:

• Physicians
• Nurse Practitioners
• Physician Assistants
• Nurses
• Pharmacists
• Case Mangers
• Medical Technicians

The PCMH coordinates care across all elements of the health care system, including specialty care, hospitals, home health care, and community services.

Mission

Deliver the highest-quality, evidence-based, patient-centered care to enrolled patients through team-oriented processes, increased access, improved provider continuity, enhanced communications, and coordinated prevention, education, and management of patients.

Vision

Ensure the operational health and readiness of all service members and ensure clinical currency of team members.

Goals

• Establish the Medical Treatment Facility (MTF) as the Medical Home for enrolled beneficiaries.
• Provide optimal patient-centered care for enrolled patients using evidence-based clinical practice grounded in established population health principles.
• Establish standard processes, clinic alignment, roles for health care team members, and continuous improvement to execute the principles of PCMH.

Purpose for Patient Centered Medical Home (PCMH) Operations.

• To deliver the highest quality, evidence-based, patient-centered care to enrolled patients through team-oriented processes, enhanced access, improved provider continuity, superior communications and coordinated prevention, education, and management of patients. This approach will provide operational health and readiness for all military members and promote optimal clinical currency for the members of the team.
• To create an innovative, rewarding, and productive practice environment that attracts and retains highly qualified, top performing medical professionals.
• To utilize to maximum effect the skills of all team members.
• To emphasize continuous improvement of team workflow processes and patient flow. PCMH operations integrate technological tools to enhance communications with patients and provide agile tracking of health parameters for individual patients and across the population of patients.

The PCMH Model of Care focuses on these core functions:

1. Patient-Centered Care: Relationship-based care focused on the whole person and understanding and respecting each patient’s unique needs, culture, values and preferences. Practice actively supports the patients in learning to manage and organize their own care at the level they choose. We recognize family members are core members of the care team and are included in establishing goals and care plans.
2. Comprehensive Care: A team of providers who work to meet each patient’s physical and mental health care needs, including prevention and wellness, acute and chronic care.
3. Coordinated Care: Care is coordinated across the healthcare spectrum to include specialty care, hospitals, homecare and community services and support.
4. Access to Care: Our goal is that patients have shorter wait times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to the team.
5. Systems-based approach to quality and safety: We use evidence-based medicine and clinical decision tools to engage in process improvement and performance measurement. We respond to patient experience and satisfaction feedback. We practice population health management and share quality and safety data and improvement activities.