About Our Practice

What is a Patient Centered Medical Home?

The Patient-Centered Medical Home (PCMH) is a care delivery model in which our patient’s treatment is coordinated through our office to ensure they receive the necessary care when and where they need it, in a manner they can understand.

The objective is to have a centralized setting with partnerships between patients, and our office, and when appropriate, the patient’s family.

A care team includes your Physician, Nurse Practitioner and our Care Management team. We also use registries, information technology, health information exchange and other means to assure our patients get the care when and where they need.

In addition, there is a group at our practice called the Patient Family Advisory Council or PFAC for short. The goal of patient and family engagement is to create an environment where patients, families, Doctors, Nurses, and other team members collaborate as partners to improve the patient experience, prevention of disease and quality of care.  In 2019 we offered a health fair to all patients.  Prevention, education and continued excellent care was the events moto, and the PFAC group achieved an award through Catholic Medical Partners for their efforts.

Patient Centered Medical Home is an accredited program through National Committee for Quality Assurance and Attestation and Audit are done every year. Our practice has achieved and maintained the highest level (Three) since 2010.

The NCQA PCMH Recognition program is the most widely adopted PCMH evaluation program in the country. More than 13,000 practices (with more than 67,000 clinicians) are Recognized by NCQA.

For practices to receive this Recognition, they must meet standards in six areas:

• Team Based Care and Practice Organization: Practices are evaluated on leadership structure, care team responsibilities, how they engage with patients, families and caregivers.
• Care Management and Support: Practice clinicians use care management protocols to help them identify patients who need closely managed care.
• Know and Manage Patients: Practices must meet standards for data collection, medication reconciliation and evidence-based clinical decision support.
• Care Coordination and Care Transitions: Practices ensure that primary and specialty care clinicians share information and manage patient referrals.
• Patient-Centered Access and Continuity: Practices provide patients with convenient access to clinical advice and continuity of care.
• Performance Measurement and Quality Improvement: Practices have processes for measuring their performance and for quality improvement activities.