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.
Other 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
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:
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.
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.
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.
