Our mission is to provide prevention and care to the community and I think the Medical Home Project was just that.

It’s taking care of people in a way that we know who they are. When they call they know that the receptionist who answers the phone knows who they are.

We think it’s important that patients come in and feel comfortable. We think it’s important that we follow-up with them. We think it’s important that if they see their primary care doctor today and need a prescription, the prescription is there before they leave the building.

Medical Home means to me that it’s a shared responsibility between their primary care physician and the patient and the patient’s family and we look at the whole patient and we decide with the patient what the best course of action is to get them to their goals for their specific disease processes that they’re trying to manage.

Medical Home really does support efficiencies in the medical system, not only through care but also financially. If we can coordinate the care between the hospitals and nursing homes and other specialties and bring people through those systems in a coordinated sense, they move out of those places faster, they come home faster and a lot less unnecessary services are needed.

We do a practice assessment where we basically looked at what our structure was currently, how we were managing patient’s care, our policies and procedures, what our job descriptions said, what our practices were for after hours and on call, what our clinical guidelines were. And we seem to be right in line with what NCQA considers the standards for care for a patient centered medical home.

We decided to go out and get NCQA, National Committee for Quality Assurance Certification for a patient center medical home for several reasons. The most important of which was that we felt this was the way we wanted to practice.

The idea to us of medical home certification is really to systematize something that hopefully we’ve been doing in the medical care all along, which is trying to make the patient the center of our care.

The first key was to have a really good electronic medical record because so much of what you need has to be able to be documented in the patient’s medical record in a format that’s useable to the physician and also accessible for reporting and just to even give a report to the patient so they know what they should be working on after the visit.

One of the things that we’ve always done is we’ve done disease management, we do outreach, we’ve always done outreach and we practice by guidelines. So athenaClinicals really supported that.

I think once you get beyond the fact that there are certain administrative requirements to receiving the certification, what you realize is it puts into place things that help you do your job better. And so ultimately I don’t think it ends up being extra work, I think that there’s the benefit of both technology and other people in our health centers help us get the work done that we need to get done to make sure patients get the care they need.

It was very helpful that we were now up on athena when we went for NCQA certification. In fact we delayed our certification because we were coming from another EMR that didn’t have the support that athenaClinicals did.

We liked the way athena can help us to put data together at the point of care to provide the right care at the right time.

A lot of medical care comes down to information management, understanding what patients need, what they’ve had, where they need to go, who they’ve seen and what needs to happen next in coordinating their care. And people are getting sicker and older and more complicated and so increasingly it’s hard to do that in a world of paper and pen.

You do have to evaluate as a practice what your strengths and weaknesses are. You do have to have an infrastructure, you do have to have an EMR, you do have to have a team concept within your organization. You have to have a culture where practitioners want to practice evidence-based medicine and embrace guidelines. You have to change your focus of how you want to take care of your patients.

We really can’t rely on the old methods, paper based methods, phone call based methods. We have to have systems that at the point of care can remind doctors, nurses, here’s the procedure, here’s the questions to ask, here’s the thing to provide to this patient right now so that their health is improved and maintained and our practice keeps providing for their needs.

It is motivating; it’s exciting because people get into healthcare because they want to help people. So when we can bring it down to everyday and you can see what you did really made a difference at that time and place.

The Patient Centered Medical Home is definitely a benefit for your patients and also ultimately I think for your practice in the long run. It will take some work to get there but once you’re there, you have everything in place to just keep building upon it and making it better and better.