Coordinating
Your Care with a Medical Home
By Carolyn M.
Clancy, M.D.
May 19, 2009
If you have a
chronic condition like diabetes or heart
disease, you need to play an active - and
sometimes unfamiliar - role in your care to stay
healthy.
For example, you
may need to take new medicines, change your diet
and lifestyle, and check your blood sugar or
blood pressure levels. Most likely, you will
need to see your doctor and other health
professionals, like nurses, pharmacists, and
other clinicians, more often than you did
before.
Managing all of
this can be a challenge. You’ll need to make
changes in your daily routine and get used to
new medicines. And you’ll want to keep track of
the advice of your care team. This may require
more appointments, more tests, or more follow
up.
You may also feel
overwhelmed by it all.
There is a better
way, however. It’s called a medical home, or a
patient-centered medical home. A medical home
takes a team approach to primary care and puts
the patient at the center of that team. The idea
isn’t new, but it’s getting tested in new and
larger ways.
Medical home
teams often work in a primary care doctor’s
office or clinic. Team members can include
doctors, nurses, pharmacists, and physical
therapists. They help coordinate their patients’
care across a range of settings, such as health
clinics, hospitals, and cardiologists’ or other
medical specialists’ offices.
How is the
medical home model different from regular
medical care?
Medical home
teams try to broaden your access to primary
care. This can reduce the risk that a medical
problem will get worse and require a hospital
visit.
A medical home
team also can help coordinate the care that you
need beyond primary care. For example, if you
have heart disease, you might need to be seen by
a heart specialist. The medical home team can
arrange for that visit, make sure you’re
prepared, and see that any test results from the
appointment are provided to you and your care
team.
Some of the
largest primary care groups in the United States
have agreed on
key principles of a patient-centered medical
home.
The groups include the American College of
Physicians, the American Academy of Family
Physicians, the American Academy of Pediatrics,
and the American Osteopathic Association.
Starting this
summer, the
Federal government (PDF File;
PDF
Help) will launch a demonstration of the
medical home model for Medicare patients. The
3-year project will test this care model for
older patients with certain illnesses that need
ongoing medical monitoring, advising, or
treatment.
Medical home
teams that want to take part in this project
must be able to track patients’ test results,
review medicines, and follow up with providers.
Doctors who use this model and have electronic
medical records are encouraged to participate.
The results of
the Medicare project will be important as our
population gets older and needs more health
care. Today, people 85 and older are the fastest
growing segment of the U.S. population,
according to the
U.S. Census. The 65 and older group is
expected to double in size in the next 25 years.
Is there a
medical home in your community? If your doctor
or your family’s doctor is a member of one of
the national primary care or pediatric groups,
he or she may be familiar with medical homes.
If no medical
homes are available near you, there still are
things you can do to play an active role in your
health care.
Talk to your doctor. Ask how he or she can
work with you to coordinate your care and keep
you informed. Being an involved, engaged patient
can go a long way toward getting you the care
you need.
I’m Dr. Carolyn
Clancy, and that’s my advice on how to navigate
the health care system.
More Information
Agency
for Healthcare Research and Quality
Questions are the Answer
http://www.ahrq.gov/questionsaretheanswer/
Centers
for Medicare & Medicaid Services
Medical Home Demonstration: Fact Sheet
http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MedHome_FactSheet.pdf
[PDF
Help]
U.S.
Census Bureau
Dramatic Changes in U.S. Aging Highlighted
in New Census, National Institutes of Health (NIH)
Report
http://www.census.gov/Press-Release/www/releases/archives/aging_population/006544.html
American
Academy of Family Physicians, American Academy
of Pediatrics, American College of Physicians,
American Osteopathic Association
Joint Principles of the Patient-Centered
Medical Home
http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.
Par.0001.File.dat/022107medicalhome.pdf
[PDF
Help]
Current as of May 2009
Internet Citation:
Coordinating Your Care with a Medical Home.
Navigating the Health Care System: Advice
Columns from Dr. Carolyn Clancy, May 19, 2009.
Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/consumer/cc/cc051909.htm
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