Patient-Centered Medical Home

A Primary Care team approach to coordinate your total health care

What is Patient-Centered Medical Home?

It is a commitment to your care.  It allows our office to use a comprehensive team approach in providing for your total health care, including preventative care, care for any sudden illness or injury, or long term chronic care. 

Patient-Centered Medical Home (PCMH) is a partnership in communication between you and your healthcare providers.  As part of PCMH, we will help you coordinate all your care to keep you at your healthiest.

Who is Part of Patient-Centered Home?  

First and foremost, your PCMH team begins with YOU.  Patient-centered means you are the focus of your health care.

Your team also includes:

• Your primary care provider
• Physicians, nurses, physician assistants, pharmacists, nutritionists
• All staff at your healthcare provider's office

What can Patient-Centered Medical Home do for you?

• Help you proactively manage all your medical, physical, social and behavioral health care needs
• Coordinate your care from specialists, labs, and other facilities as well as any medications you take
• Have members of your care team accessible to answer your health questions or concerns
• Work closely with health coaches, pharmacists, registered dietitians, nurse care coordinators, counselors, and family members to ensure that your care is coordinated across all settings
• Provide educational materials and literature that uses evidence-based guidelines to help you self-manage your and your family’s health
• Assist in transferring or receiving your medical records

What do you need to do?

• Be an engaged and active participant:
  • Follow the health care plan you and your team agreed on
  • Set goals you can reach; and once reached, discuss new ones
  • Let your team know if you are having trouble staying on track or if your care plan is not working for you
• Keep your providers informed. Tell us about the care you receive from other healthcare professionals
• Provide any facility or physician outside of our office with our contact information
• Provide a complete medical history to us
• Call us first with questions about your health and appointment requests before visiting an Urgent Care or Emergency Room
• Hospitalized? Call us as soon as you are discharged to set up follow up appointments
• Bring a list of your medications to your visit. Let us know when any of your medications have changed

PCMH and our Quality Outreach Team

• At General Physician, PC, we have a Quality outreach team as part of PCMH that will monitor your healthcare needs and communicate with you regarding all your preventative screenings.
• Our Quality team continuously reviews the quality of service we provide and welcomes your feedback to improve your experience.

When you Need Specialty Care

• Your primary care physician and staff will help you find the right specialist and get an appointment.
• We will send pertinent information about your medical history and test results to the specialist.
• Our providers will work with specialists and other medical facilities to coordinate your care.

Electronic Health Records

• Our comprehensive Electronic Health Record system allows us to securely keep track of your medical care, determine when you are due for services, remind you to schedule appointments, and communicate with you.
• The patient portal allows you to stay in touch and updated while tracking your medical progression.