Patient-Centered Medical Home
Coastal Medical is a Patient-Centered Medical Home (PCMH) Group Practice
A Patient-Centered Medical Home (PCMH) is a primary care medical office that puts the patient in the center of their health care. The PCMH model of care creates care teams that help patients understand all of the services that they will receive today, or may need in the future - even if the services are not being provided in the primary care office.
PCMH practices like Coastal Medical are collaborative. Providers work as a team with in-office Nurse Care Managers and Clinical Pharmacists, as well as hospitals and specialists (e.g. cardiologists, urologists, behavioral health professionals, nutritionists, etc.), as needed, to ensure each patient gets the care they need at the right time.
Coastal Medical PCMH practices focus on preventive care. This model helps spot health concerns earlier and manages chronic conditions. At Coastal Medical, our heath care teams partner with patients and their families and make every effort to understand and respect each patient’s unique needs, culture, values, and preferences.
Our PCMH practice supports patients in learning to manage and help to organize their own care. We want you to be an active member of your care team. Recognizing that patients and families are core members of the care team, PMCH practices like Coastal Medical work with patients to provide proactive, comprehensive care, better access to care and more coordinated care for patients.
What is a care team?
A well-functioning PCMH is all about a team of people working together towards a common goal: delivering exceptional health care to patients. Every member of the team, including the patient, needs to know that their efforts and ideas are valued. Coastal Medical care teams are led by your physician and includes: nurse care managers, pharmacists, medical assistants and the entire office staff – everyone on the team is working for you.
What is your role on the team?
- Prepare questions for your team before your visits as a reminder during your visit.
- Share successes and challenges you have had with your care in the past.
- Tell your Coastal team about other healthcare providers caring for you.
- Take care of your health by following the plan you and your team have designed for you.
- Set goals you can reach and sincerely work toward them..
- Talk openly with your team, if you are having trouble sticking to your care plan, let someone know.
- If you feel the plan is not working, speak up and ask for changes.
- Message your care team in between visits on the Patient Portal, as necessary.
What is the patient portal?
The Coastal Medical Patient Portal allows you to log into our secure system and manage your health care from any location with internet access.
On the patient portal you can:
- View Personal Information
- View Your Health Record
- Receive Educational Materials
- Receive Appointment Reminders
- Request Prescription Refills
Not registered on the Portal? Contact your Coastal practice to register today.
Preventative care is care that focuses on disease prevention and health maintenance. It includes early diagnosis of disease, discovery and identification of people at risk of developing specific problems, provides counseling, and other necessary intervention to prevent a health problem before it becomes chronic. Screening tests, health education, and immunization programs are common examples of preventive care.
To be recognized as a PCMH practice, each of our medical offices must meet a set of quality standards in patient care – this means our providers are more accountable than ever for the care they provide. Coastal practices are NCQA recognized – this is the highest level quality rating that can be achieved at this time.
What is NCQA Recognition?
National Committee for Quality Assurance (NCQA) identifies and recognizes physicians who deliver superior care using standards firmly rooted in medical evidence. NCQA Annual Patient-centered Medical Home Recognition highlights the commitment to provide quality health care to patients and demonstrates that we have incorporated quality improvements into our practices. Recognition is awarded after annual evaluation by NCQA on many aspects of our medical office practices and performance, including, Access and Communication; Patient Tracking and Registry Functions; Care Management; Patient Self‐Management Support; Electronic Prescribing; Test Tracking; Referral Tracking; Performance Reporting and Improvement; and Advanced Electronic Communications.
What is Comprehensive Care?
As a PCMH, Coastal practices are accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, nurse care managers, physician assistants, clinical pharmacists, nutritionists, social workers, educators, and care coordinators, such as office staff.
What is Coordinated Care?
At Coastal, we manage our patients care across all parts of the health care system, including specialty care, hospitals, home health care, and community services and supports. This kind of coordination is particularly important during transitions between sites of care, such as when patients are being discharged from the hospital. Coastal practices provide Nurse Care Managers to patients transitioning from hospital to home. We have found that the support of the nurse care manager lowers the chance of readmission to the hospital. We work hard at building clear and open communication among patients and families, as well as the rest of the medical care team.
Better Access to Care
PCMH practices like Coastal Medical offer shorter wait times for appointments, weekend and/or evening hours for appointments, and around-the-clock telephone or electronic access to personal health information. Coastal Medical is working hard to provide improved access for our patients by offering same day in-office sick visits and laboratory services as well as weekend and holiday sick visit by appointments, better access to specialists, access to your health information through our Patient Portal, and a wealth of health information and physician contact information on our website.
An Organized Approach to Quality and Safety
Our PCMH practices demonstrate a commitment to quality improvement by regular participation in the use of evidence-based medicine and clinical decision-support tools to help patients and families make decisions about their healthcare. By taking part in performance measurement and improvement efforts, and measuring patient experiences and patient satisfaction, as well as practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.
What is Evidence-Based Medicine?
The careful and regular use of the best current medical evidence in making decisions about the care of each individual patient. Evidence-based medicine (EBM) is meant to integrate clinical expertise with the best available research evidence and patient values. EBM was initially proposed by David Sackett, MD, and colleagues at McMasters University in Ontario, Canada.
The Electronic Medical Record and Why Is It important?
An electronic medical record (EMR) is a digital version of the traditional paper-based medical record for an individual. An electronic health record (EHR) is an official health record for an individual that is shared among multiple facilities and agencies such as your physician, your specialist or the hospital where you have been treated. The EMR is very important because your physician can monitor whole groups of patients and, based on the information in “the record” can know what proactive steps to take to keep you healthy.