Patient Centered Medical Home

What is a “Patient-Centered Medical Home?”

What is a “Patient-Centered Medical Home?”

As defined by the National Committee for Quality Assurance (NCQA), Patient-Centered Medical Home (PCMH) is a way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.

Essentially, a PCMH offers a new patient0centered approach utilizing a team of medical professionals and technology, to provide the best possible care for you in their office with the input from you and your family.

How a patient-centered medical home works for you

In a PCMH, your care team:

  • Is available 24/7 if you need them. You can communicate with your team by phone or email, and you can get an appointment quickly, even on the same day if needed.
  • Knows you and remembers your health history. They know enough about your personal or family history to suggest treatment options that makes sense for you.
  • Makes you understand your condition(s) and how to take care of yourself. They help you sort through your options and make decisions about your care.
  • Helps you coordinate your health care- even if they are not giving the care themselves. They will help you find specialists, get appointments, and make sure those specialists have all the information they need. Your PCHM team will also be sure you know what the specialists say and what it means for you.

A Patient-Centered medical Home is about you

Caring for you is the primary focus of a PCMH. Your care in a PCMH is personal, and your team’s job is to deliver the health care you need.

Who is part of the PCMH team?

The PCMH Team will work like many athletic sports teams. There is a primary doctor (head coach) Nurse (Assistant Coach), as well as other health care professionals who may assist in your care, such as: pharmacists (Defensive Coordinator) and physical therapists (Offensive Coordinator). Your family caregivers are also included in your team (Fans).

With a team approach and the input from your “coaches” and “fans,” you will feel like a “star Player” of the team- with a championship level of care!

Getting the most from the patient-centered medical home

What your PCHM team should do:

  1. Learn about you
  • Get to know you, your family, your life situation, and preferences. Remember these details about you every time you seek care and suggest treatments that make sense for you.
  • Treat you as a full team member in your care.
  1. Communicate with you
  • Give you time to ask questions and answer them in a way you understand
  • Make sure you know and understand all of your options for care
  • Help you decide what care is best for you. Sometimes more care is not better care.
  • Ask you for feedback about your experience getting care.
  1. Support you in caring for yourself
  • Make sure you leave the office with a clear idea of how to care for yourself
  • Help you set goals for your care and help you meet your goals one step at a time.
  • Give you information about classes, support groups, or other types of services to help you learn more about your condition and stay healthy.

What you can do:

  1. Learn about caring for yourself
  • Know that you are a full team member in your own care
  • Learn about your condition and what you can do to stay healthy as possible
  • As best you can, follow the plan that you and your PCMH team have agreed is important for your health. If you have questions, ask!
  1. Communicate with your PCMH care team
  • Always bring a list of questions to each of your appointments. Also bring a list of any medicines, vitamins, or remedies you use.
  • Always tell your PCHM team when you don’t understand something they said. Ask them to explain it in a different way.
  • Always tell your PCMH Team if you get care from other health professional, so they can help coordinate the best care possible.
  • Always talk openly with your PCHM Team about your experience getting care from the medical home, so they can make care better.

What does PCMH mean to me as a Big Sandy Health Care patient?

PCMH means that the care that you receive at any our Big Sandy Health Care sites will focus on you and your individualized needs. You will be included in the planning and coordination of your care. You will be able to choose your own provider and have an active role as part of the clinical team. Big Sandy Health Care (BSHC) will ensure that you will have access to the services you need and will be available 24/7 for questions and concerns about your care or treatment plans.

How do I reach someone if I need assistance after hours about my care, concerns, or treatment?

You can call our nurse on call. Our nurse on call is available 24/7 including weekends and holidays. You reach the nurse on call by calling any of our BSHC phone numbers and pushing #1.

Big Sandy Health Care provides comprehensive care incorporating evidence based care and self –management support.

Centers for Disease Control:

United States Preventative Task Force:

American Academy of Pediatrics:

             American Diabetes Association: