Medical Home Certification

Principles for Patient-Centered-Care:

As an organization representing a broad and diverse array of consumer interests, we believe the following should guide the development and implementation of the medical home model of care:

In a patient-centered medical home, and interdisciplinary team guides care in a continuous, accessible, comprehensive and coordinated manner.

• The patient is the center of the care team. Family members and other caregivers may also be a central part of the team.

• The care team includes professionals inside the medical office or health center, as well as clinical and non-clinical professionals in the community.

• The team provides initial and routine assessments of the patient’s health status, and places a high priority on preventive care, care coordination and chronic care management to help patients get and stay healthy and maintain maximum function.

• The care team is led by a qualified provider of the patient’s choice, and different types of health professionals can serve as team leader.

Performance Reporting

Middlebury Family Health saw an opportunity to improve the number of Annual Physicals with patients over 65 years of age. In February of 2013 only 26% of our patients 65 and over had their Annual Physical. After reaching out to patients, we saw an improvement of 47% which brought us to 73% of patients over 65 that had their Annual Physical in 2015.

Diabetes is a chronic health condition that affects a high percentage of our patients. We monitor monthly A1c levels for all diabetics. In June of 2015 17% of our patients had an A1c over 8. After increasing follow up visits and utilization of our in house dietician, we are now at 9% of diabetic patients with an A1c over 8. That’s an 8% improvement.

November 2014 Annual Survey Results

91% of patients felt the office reviewed all the prescription medicines they were taking. (National average 90%)

91% of patients felt the front desk staff treated then with courtesy and respect. (National average 82%)

81% of patients felt the front desk staff was always helpful. (National average 68%)

85% of patients stated their provider always explained things in a way that was easy to understand (National average 84%)

86% of patients stated that their provider showed respect for what they had to say. (National average 88%)

77% of patients said that they always obtained an appointment as soon as needed for care right away. (National average 66%)

71% of patients stated that they always received same day response as soon as they needed to phone calls made after regular office hours. (National average 62%)

Patient comments:

“Excellent medical care”

“What an amazing bunch of caregivers – great job”

“We have always been treated very well and we have great confidence in our Physcian”