Wouldn’t it be great if no matter what was bothering you or what blood work or tests you needed to get done, you could always go to one place and get everything taken care of all at once? In today’s often difficult to navigate health care system, many people wish they had a one-stop place to take care of all their ailments and be on their way. I am lucky to be serving at a site that is working to do just that. At the Shadyside Family Health Center (SFHC), a model has been taken on called the Patient Centered Medical Home (PCMH). This model promotes exactly what it sounds like: it is transforming the way primary care is organized and delivered by keeping all of the patients’ needs as the center focus.
There are five components to PCMH: comprehensive care, patient-centered, coordinated care, accessible services, and quality/safety. In order to accomplish comprehensive care, it takes a diverse team of health care providers like nurses, physicians, pharmacists, nutritionists, social workers, educators, and care coordinators, etc. to be all in one place, or at least virtually connected to the primary care visit. The mindset is that the patient plays a crucial role in the decision-making regarding their care and the whole person is taken into account. Coordinated care is provided through the open communication of all entities and outside services the patient might need. Additionally, access for urgent needs is easier and there is constant evaluation and updating of methods while using population management to improve the quality of delivery, and thus, outcomes. Patients receive care with physical and mental health, acute or chronic care, and prevention and wellness care all under one roof.
In my role as Diabetes Quality Improvement Coordinator, I am able to help coordinate the chronic care management, prevention, and wellness strategies that patients need. Seeing how I am just a part of the bigger team of care that a patient may come across in just one visit is encouraging. As an example, a patient who was diabetic came in recently and met with the physician, then the pharmacist to take about medications and how to test blood sugar, and then met with me to discuss nutrition and setup times to talk about lifestyle measures to help manage her diabetes. I am learning about how all parts of the patient’s care fit together. At SFHC I am fortunate enough to have two other Corps members working with mental health and maternal/child health and we can see just how our roles and others overlap. The PCMH model takes effort and coordination from varying areas but, when demonstrated, can be hugely helpful to the patient.