Your Patient-Centered Medical Home
UT Medicine was awarded a rating as a Level 2 Patient-Centered Medical Home by the National Committee for Quality Assurance (NCQA).
The concept of a “patient-centered medical home” (or PCMH) has been around for more than 40 years. It is only in the last decade that studies have confirmed the benefits of patients having a “home base” for their health care. Many doctors knew it as common sense and a smart thing to do, but it is now backed up by many scientific studies; when you go to the same doctors and they get to know you well, your health care will be better. And when those doctors act as a team to take care of you - with your family doctor coordinating the team - it makes for better decisions on your health care.
This concept is now widely recognized by many organizations, including the American Academy of Family Physicians (AAFP), the American Medical Association (AMA) and the US Department of Health and Human Services (HHS - which runs Medicare) – as the best way to take care of people. These groups rely on outside organizations like the NCQA to certify that groups like UT Medicine are doing what it takes to be a patient-centered medical home.
To qualify for this rating, UT Medicine’s patient-centered care program was reviewed by the NCQA over a six-month period. The NCQA is a private, non-profit organization dedicated to improving healthcare quality. It acts as an independent organization to evaluate and report on quality for physicians groups, health plans and other healthcare related companies.
There are six key things to look for in a medical home, and these items are what the NCQA looked at before awarding the rating that assures you that UT Medicine has a strong patient-centered medical home.
- Access: This means making sure to meet the patient's needs during normal business hours, but also after business hours when they might call in with a prescription problem or need guidance on how to care for a new medical problem or complication.
- Team-based care: Some medical problems may require the expertise of multiple experts to get optimal treatment and function. Some problems may need behavioral health interventions, others may need expert guidance from a clinical pharmacist to help with the adherence to recommended medications, or others may need coaching for increasing physical activity and healthy diet guidance from a dietician or nurse care manager. The patient’s personal physician leader works with the other experts (other doctors, nurses, pharmacists, physical therapists, nutritionists, etc.) to help patients manage their “whole” healthcare picture. It also includes being aware of any cultural or language needs the patient might have, and bringing in new team members to help with these things.
- Care coordination and care transitions: This is especially beneficial for older people who have many health issues. Coordinating care means keeping track of all of your health issues and helping to coordinate tests or referrals to new doctors – or referrals to other places such as a hospital, an emergency room or a retirement home or hospice care.
- Evidence-based guidelines: Although this may sound complicated, it is not. It simply means making sure that scientific evidence (based on studies and clinical trials) is what the doctors use to make decisions for their patients. This is especially important for preventive care such as immunizations for adults and children, and for cancer screening tests. The same standards of evidence also apply for how we care for chronic diseases, like diabetes, high blood pressure and asthma.
- Population health management: This is another complex sounding phrase that simply means looking at all our patients and using information about them to see how they are doing as a group. Your health information is always kept private – that’s the law. But we can take pieces of it (we leave your name off it to keep it private) to look at health markers in groups of patients. This means looking at things like all our patients’ average blood sugar levels or blood pressure or cholesterol levels. This can tell us if we are being successful at improving the overall health of the community in San Antonio. In addition, it includes looking at gaps in care for patients who have not been to the office recently and reaching out with needed services to optimize their care and prevent complications.
- Performance measurement and quality improvement: This is related to the “population health management”. It’s about using our information and looking at ways that we can do things better and that means making our patients healthier. We always want to get better at what we do and make you healthier – and that’s what “continuous improvement” is all about. It is also about having a commitment to constantly make changes – big or small – in our processes to improve the patient experience.
The National Committee for Quality Assurance (NCQA) is governed by a Board of Directors that includes employers, consumers, health plans, quality experts, policy makers and representatives from organized medicine. Learn more about the NCQA.