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Reimagining Healthcare: The Patient-Centered Medical Home

Reimagining Healthcare: The Patient-Centered Medical Home

Codman Square Health Center in Dorchester was recently recognized as the highest level of Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). This sounds like an important recognition, but what exactly is a Patient-Centered Medical Home? And what does this mean for the health center’s patients?

The Patient-Centered Medical Home Model

The term “Patient-Centered” is simply a way of saying that the patient is the most important person in the healthcare system. The “Medical Home” is a way of referring to one place where you can receive total healthcare. At a Patient-Centered Medical Home, patients are invited into a care team that includes their healthcare provider, nurses, educators, counselors, community programs, and, for those who would like it, trusted friends or family members. This kind of collaboration requires new standards of access and communication that transforms how healthcare has often been delivered in the past. A health center’s transformation into a PCMH is a complex and far-reaching process in which no part of the organization remains untouched.

At Codman Square Health Center (Codman) the transformation into a PCMH has been a gradual process over the course of many years, but recently, staff have begun to recognize the way these new standards are improving healthcare.

“Since we started Patient-Centered Medical Home, I feel much more useful and more connected to our patients. Patients are now calling me and know me as someone who can help. It feels good. I think me and [my doctor] are a better team and more productive. I’m thinking more about how the clinic works together to provide good care for our community,” stated Melissa Edouard, a medical assistant at Codman.

In addition to increasing staff involvement and collaboration, numerous studies have shown that practices adopting the PCMH model have reduced hospital admissions and emergency room visits, increased rates of cancer screening and improved management of diseases like diabetes and asthma.

Dr. Ethan Brackett, a family medicine provider and one of the champions of the Patient-Centered Medical Home initiative at Codman, is thrilled about this new way of approaching healthcare. “I have a completely different set of priorities coming into work or thinking about a patient’s case now that PCMH has started to seep into our culture here at Codman,” he said. “PCMH has made me question how we spend our time in a patient visit — what percent of the stuff I was trained to do really impacts the bottom line of my patients’ health? Now that I know more about the impact of health behaviors, I am happy to let my team prioritize self-management goals, review clinical visit summaries with patients and do interval outreach to my sicker patients. I’m excited by the direction PCMH is taking us.”

Ways It’s Changing Patient Care

•    Care is delivered by a whole team of professionals.

•    Most patients will receive a Care Visit Summary, which details everything that took place during their visit to the health center, including their care plan going forward.

•    Most patients will receive follow-up calls after a visit to an emergency room in order to check in on their status and provide follow-up care if needed.

•    Patients receive more direct outreach and home visits from their care team.

A Patient of a Medical Home

Mrs. M is a diabetic patient who has been coming to Codman for over five years. Prior to PCMH, her blood glucose levels were always too high. She loves her provider, the health center and her care, but she never understood why her doctor remained concerned about her health. Since the start of the PCMH, Mrs. M has had a drop in her blood glucose levels and has become more engaged in her care. She tried and liked the fitness and nutrition classes for seniors at Codman and thinks she might even go to the Healthworks Community Fitness gym, a community partner of Codman. She has taken an interest in the Care Visit Summary she receives at the end of each visit and uses it to share medical information with her family. Although hesitant at first, she agreed to a home visit from a community health worker (CHW) and now has regular meetings with the CHW at Codman to review her health, behavior and upcoming appointments. She now understands when and why she needs diabetic screening labs, and has started shopping at the Codman farmer’s market.

More Information

To find out more about Codman Square Health Center and the PCMH Model, visit