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Becoming a Patient-Centered Medical Home: What’s in it for our patients?

Becoming a Patient-Centered Medical Home: What’s in it for our patients?

Paulette Shaw Querner, RN, MBA
Corporate Vice President, Community Health Centers,
Harbor Health Services, Inc.

After undertaking a challenging and complex application process that required more than one year to complete, the Geiger Gibson Community Health Center, the Mid Upper Cape Community Health Center and the Neponset Health Center were recently awarded the highest possible recognition from the National Committee for Quality Assurance (NCQA) Physician Practice Connections® (PPC)-Patient-Centered Medical Home ™ (PCMH) Program.

NCQA is a not-for-profit organization dedicated to improving the quality and coordination of care in the nation’s health system. Building on joint principles developed by primary care specialty societies like the American Academy of Family Physicians, the PPC-PCMH standards emphasize the use of systematic, patient-centered and coordinated care that supports access, communication and patient involvement. The 17 physicians and 16 nurse practitioners working at the three health centers are among a handful of providers in the state to receive this recognition.

The Patient-Centered Medical Home model of care is certainly not new to us. One can say that the first community health center in the country — our very own Geiger Gibson Community Health Center — was established on the principle of tailoring comprehensive health services to meet the specific needs of residents living on the isolated Columbia Point peninsula in Dorchester. Fast forward to today’s complex world of medicine and that same notion of developing a support system around the patient not only remains at the heart of community health center care, but is now being promoted as the basis for transforming the nation’s health system.

But more importantly, what does this mean for our patients?

A patient-centered medical home model provides benefits for both patients and caregivers. Patients gain more one-on-one time with their physicians and have access to a team of providers that can include nurse health educators, optometrists, podiatrists, pharmacists, nutritionists, dentists and mental health counselors — all in one place. What’s more, these providers work together to ensure that each patient receives the care they need to maximize their overall health and well being. And when a patient needs specialty or hospital-based care, our health centers have built strong relationships with multi-specialty practices and academic and community hospitals to which they can refer patients, all the while tracking their progress and treatment regimens.

It also means that patients take more responsibility for their health. Our health center patients become active participants in their care, asking questions, setting goals and following the advice of their health care team members. This includes taking medications prescribed to them by their physicians as well as communicating changes in their health and/or chronic conditions to ensure that their medical records remain up to date.

Long before we were recognized as a Patient-Centered Medical Home, our patients had access to a team of clinical pharmacists and clinical pharmacy residents whose mission has been to work side by side with the health centers’ primary care providers and their patients in optimizing medication therapies through patient education, medication adherence strategies and medication reviews. Neponset Health Center currently operates a retail pharmacy; Geiger Gibson will open one of its own in the spring of 2011 with Mid Upper Cape following close behind.  Now patients will enjoy the benefits of having their retail pharmacist as part of the Medical Home on-site team.

Ongoing, timely communication is one of the most important elements of a successful Medical Home. Physicians and nurse practitioners at Geiger Gibson Community Health Center, Neponset Health Center and Mid Upper Cape Community Health Center use health information technology in communicating patient information, collecting and analyzing patient data and for tracking and coordinating care. Implementation of Electronic Health Records at the three health centers has greatly enhanced their ability to provide timely information to patients and caregivers, develop patient treatment plans and reduce the chance for medical errors across the health system.   

To ensure access to care for our patients, the Harbor Health Community Health Centers offer extended evening and weekend hours, while we are working toward open scheduling and centralized call centers. Implementing open access allows the patient to schedule an appointment faster, and in many cases the same day of their call or within a few days thereafter, which helps to eliminate long waiting lines, unnecessary visits to the emergency room, improves patient care and makes for happier patients. Our Geiger Gibson Community Health Center already offers open access scheduling and is leading the way in piloting a call center.

At Harbor Health we pride ourselves in delivering culturally and linguistically appropriate care from the time our patients walk through our doors. Based on ongoing market research and the implementation of Electronic Health Records we are now in a better position to identify the ethnicity and linguistic needs of a patient. The Neponset Health Center is staffed with Vietnamese medical interpreters, case managers and nursing staff responding to the needs of the growing Vietnamese population in Dorchester and the South Shore communities. Most of our Geiger Gibson Community Health Center providers and support staff speak Spanish, while the Mid Upper Cape Community Health Center single-handedly has captured the Brazilian Portuguese speaking immigrants living and working at Cape Cod.

Every year we administer patient satisfaction questionnaires and focus on areas that need improvement. For the past several years, we received high scores in patient satisfaction including access, treating patients with respect, listening to their needs and providing them with necessary information and resources for a healthier living.

Geiger Gibson Community Health Center, Mid Upper Cape Community Health Center and Neponset Health Center are divisions of Harbor Health Services, Inc. For more information, visit or call 617-533-2212.

Physician Practice Connections® -Patient-Centered Medical Home ™ is a registered trademark of the National Committee for Quality Assurance.