FEATURE | Posted Aug. 8, 2014

Patient-centered primary care

Prestigious recognition rewards efficiency, quality and innovation

doctor and patient, copyright UC Regents
In medical practices operated as patient-centered medical homes, care teams use technology and health-management tools to engage patients as active partners in their care.

All 18 UC Davis Medical Group primary care clinics received recognition in July from the National Committee for Quality Assurance (NCQA) as Patient-Centered Medical Homes, a designation that rewards primary-care providers for efficiency, quality and innovation in primary care.

The Patient Centered Medical Home concept is an innovative approach to primary care that relies on multi-disciplinary teams to provide care centered on patient needs and preferences. Care teams use technology and health-management tools to offer patient-specific options and to engage patients as active partners in their care.

PCMH logoOther national leaders in integrated care that have achieved this designation include the Mayo Clinic and Beth Israel Deaconess Medical Center.

“Achieving the Patient-Centered Medical Home designation reflects the many ways that UC Davis emphasizes the primacy of our patients in the delivery of primary care,” said Thomas Balsbaugh, medical director for the Patient-Centered Medical Home and care coordination at UC Davis. “We provide a multi-disciplinary team to patients and families, and offer culturally relevant, proactive care.”

Coordinated care, expanded access

Organizing care around patients allows UC Davis to:

  • Offer patients better access through expanded hours and online communications.
  • Prevent problems and manage chronic conditions to keep patients healthy.
  • Coordinate care with specialists, hospitals and other providers.
  • Assist patients and families in understanding and evaluating personalized treatment options.
  • Engage patients as partners in making informed health care decisions.

Coaching and support for patients

doctor and patient, copyright UC Regents
Patient-centered medical homes emphasize prevention of medical problems and high-touch management of chronic conditions.

Some of the specific achievements and features of UC Davis’ medical home:

Vaccination rates: During the most recent flu season, UC Davis primary care clinics increased the overall vaccination rate of their patients to 60 percent, compared to a usual rate of 40 percent. One clinic reached a vaccination rate of 72 percent.

Using a proactive approach, front-desk staff, medical assistants, nurses and physicians identified patients who had not been vaccinated and encouraged them to receive the vaccine. Offices used the electronic health record to contact unvaccinated patients through a telephone system to remind patients about being vaccinated.

For patients with chronic diseases, such as heart failure, depression and diabetes, the medical home provides coaching and extra support between visits. The UC Davis Health Management and Education Program offers classes and one-on-one care managers. Patients may self-refer, or receive a referral from their doctors, to Health Management and Education for assistance with smoking cessation, weight loss and nutrition. 

Coaching: Patients with complicated conditions have access to personal care managers, licensed clinical social workers or registered nurses who can provide telephone coaching and support between visits. Pharmacists, psychiatrists and registered dietitians also are part of the care team. 

UC Davis patient Margaret Fauci said the Health Management and Education program helps in a wide variety of ways with the management of her chronic obstructive pulmonary disease or COPD, a progressive condition that causes breathing difficulty.

"There are too many things to count – from helping me health-wise by giving advice, telling me when I need to call my doctor, and following up and taking care of things I can't possibly do on my own," she said. "I'd like to keep [the program] forever."

Health-care technology: such as the patient-managed “MyChart” system, allows primary-care clinics to serve as an integrated “medical neighborhood” by linking together primary care doctors, specialists, lab services, radiology and the hospital at UC Davis Medical Center. UC Davis’ strength in using technology earned it “Most Wired” status from Hospitals & Health Networks magazine.

Respected standards

The NCQA worked with the four national organizations representing primary care physicians and other stakeholders to develop a set of standards for a patient-centered medical home. The national organizations are the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association. The NCQA identifies and recognizes medical practices that demonstrate the standards for patient-centered medical homes.