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

Goal: Tracking to ensure patients are seen by their designated provider

Result: 88% on average were able to see their designated provider

Goal: Tracking to ensure follow up calls are made for patients being discharged from the hospital

Result:  99.47% received a follow up call post discharge

Goal: Patient access – Survey result for question #11: In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

Baseline result: 71%

Action to improve: Hired more staff, changed incoming greeting, added RX line to reduce volume

**pending re measurement in the Fall of 2023

Survey Results – click link below:

Annual Survey Results