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; Plugin Software 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.
Agency for Healthcare Research and Quality
Questions are the Answer
Centers for Medicare & Medicaid Services
Medical Home Demonstration: Fact Sheet
http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/MedHome_FactSheet.pdf [Plugin Software Help]
U.S. Census Bureau
Dramatic Changes in U.S. Aging Highlighted in New Census, National Institutes of Health (NIH) Report
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 [Plugin Software Help]
Current as of May 2009
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