Patient-Centered Medical Home (PCMH) Model of Care
The Holy Cross Medical Group Mercy Family Life Center Practice is recognized by the National Committee for Quality Assurance (NCQA) as a Level 3 Certified Patient Centered Medical Home (PCMH) facility, which is the highest level achievable. The PCMH concept proactively engages patients in their care with their physicians who work collaboratively with their team using evidence-based medicine and clinical practice guidelines. These teams coordinate and closely track patient progress aligned with Holy Cross Hospital’s commitment to explore new avenues of improving the health of our patients as well as members of the community at large. Patricia J. Aurelien, DO, and Fabio E. Su Diaz, MD, MHA, FAAFP, have been instrumental in creating the PCMH model of care at the Holy Cross Medical Group Mercy Family Life Center in Pompano Beach, FL. They have a thorough understanding of the clinical aspects of their patients’ needs in a practice serving many Spanish- and Creole-speaking patients, as well as those who are underinsured, uninsured and, in many cases, undocumented. They had tremendous participation in the areas discussed below:
Restructuring: An initial step was revisiting our understanding of patient and clinical team needs. We identified ways to better meet patients’ needs and how to enable clinicians to continue to provide the same high quality of care structured in a way that tracks, monitors and reports on patient progress.
Creating Collaborations: Several hundred patients at the practice live with hypertension, hyperlipidemia and diabetes. The appointment schedule is reviewed well in advance to identify these patients. As appointments are scheduled, a nurse reviews their records to determine if tests were ordered and completed and, if not, follows up with the patient prior to the appointment.
Ensuring Accessibility: Appointment times were increased initially to allow for more comprehensive patient visits. Additionally, several slots are left open for patients who call in and need to be seen that day or the next.
Communication & Trust: In forging impactful patient engagement, the healthcare teams are mindful of cultural behaviors and language barriers. Trust must be developed among a population with many unaccustomed to ongoing relationships with healthcare providers.
Education that Empowers: In addition to a clinical summary with physician recommendations, patients are provided with informational materials customized to their individual needs so that they can be an active participant in their care at home. While conforming to HIPAA regulations, caregivers, including family members are enlisted to help.
Electronic Health Records (EHR): The Holy Cross Medical Group offices are equipped with various robust EHR tools, including a disease registry that collects data beyond one provider allowing us to track patients who receive care elsewhere, thereby identifying opportunities to close our patients’ care gaps in relation to clinical practice guidelines.
There are currently five Level 3 Certified Patient-Centered Medical Homes in the Holy Cross Medical Group, and we plan to create several additional PCMH facilities in the future.