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What is a patient-centered medical home?

A patient-centered medical home (medical home) is an approach to health care that aims to organize primary care coordination across multiple settings in an effort to help patients achieve and maintain good health.

It transforms primary care into "what patients want it to be." Medical homes can lead to higher-quality health care and lower costs, while improving the experience of care for patients and providers.

As part of a health system that participates in a medical home, USMD primary care physicians (PCPs) provide patients with access to high-quality, evidence-based care, patient and family education materials and self-management support. 

USMD PCPs are committed to providing every patient with the best care at the right time, in the right setting and with electronic technology. USMD uses nationally recognized guidelines to prevent and treat diseases while also directing and coordinating comprehensive and continuous care across multiple settings.

Patients and providers working together

A medical home works best if providers and patients partner to achieve optimal health. As part of this process, it is important that patients provide their PCP with a thorough and complete medical history. 

It is also important that patients inform their PCP if they make the decision to see other providers or if they are admitted to a hospital or the emergency department. This allows the PCP to communicate with the other specialists and health care providers to ensure continual coordination of care.

Communicating electronically with your PCP

All USMD patients are encouraged to sign up for NextMD. NextMD is USMD's secure, password-protected internet portal that allows patients and their PCP to send confidential communications. 

Through NextMD, patients can also review and print recent labs, request medication refills, request non-urgent appointments and find useful information on many diseases, conditions and medications.

Reaching your USMD clinic

You are always able to connect with your USMD clinic during regular office hours and after hours. To do so, please contact your clinic directly via phone. Patients are also encouraged to use NextMD to communicate directly with their PCP for non-urgent needs.

We are here for you 24/7

USMD is available 24 hours a day, seven days a week to assist patients with urgent medical problems. Patients are encouraged to contact their USMD physician on call when after-hours care is needed and when their office is closed. 

Please contact your PCP's office to initiate the on-call service in order to secure and receive the assistance you need. If a patient does require urgent care or is hospitalized, as soon as that patient's PCP is notified, USMD strives to obtain the patient's health information and send it to the PCP to help further coordinate care.

How can I participate?

Follow your doctor's plan, including regular follow-up visits and therapies as prescribed.

  • Let us know if you have any difficulty affording your medications. We might be able to help.
  • Call our office if you are admitted to a hospital and/or have visited an emergency room.
  • Let us know if you are seeing a specialist.
  • Sign up for NextMD, our secure, password-protected internet portal that allows you to review and to print recent labs and other tests, ask for refills, request non-urgent appointments, and find useful information on many disease conditions and medications.
  • If you feel you have an urgent problem or minor emergency, please call us first. Even after hours or on weekends, someone is available 24 hours a day to help you.

More information about the medical home program can be found at www.medicalhomeinfo.org.

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  • A medical home is an approach to primary care. It involves a partnership between the patient, the physician, family members and other professionals who participate in a patient's care. Quality, preventive care and safety are key in a medical home.
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  • The American Academy of Pediatrics introduced the medical home in 1967. Medical home concepts are based on patient-centered principles of providing health care that is designed to keep a patient healthy.
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  • Medical homes provide physician-directed health care, whole-person orientation, coordinated and integrated care, a focus on quality and safety and enhanced patient access to care.
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  • At the base of the medical home is an ongoing partnership between the patient and their personal PCP. Patients receive reminders about appointments and screenings, as well as other support to help them and their families manage chronic conditions.

    Additional services include e-mail communications, patient-satisfaction surveys and online tools to help patients manage their health information and make informed decisions. The PCP helps to assemble a team when specialists and other health care providers are needed. The ultimate goal is to take care of the whole person.

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  • A medical home is an additional service you receive for being a USMD patient. There is no additional charge. In a medical home, the patient's costs are the same as the costs for traditional health care services.
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  • With a medical home, the care approach shifts based on each patient's needs. A patient's care team may consist of nurse practitioners, physician assistants, nurses, medical assistants, care coordinators, nutritionists, educators, pharmacists, case managers and behavioral health professionals.

    The care team may also include community resources and home health or hospice care services. Any member of the care team can provide treatment, education, assistance and communication to the patient.

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  • In some cases, your PCP will oversee your behavioral health concerns. However, in some instances, your PCP will refer you to an outside behavioral health specialist to manage and oversee your behavioral health concerns.

    If you are referred to an outside specialist, your PCP will work closely with that specialist to co-manage your behavioral health needs.

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  • A care coordinator is a nurse or clinical specialist that works with the medical home PCP to help care for patients. The care coordinator:

    • Provides education and answers questions about a patient's medical condition
    • Acts as a liaison with insurance companies to locate support programs related to medications or health care services
    • Coordinates care after discharge from a hospital
    • Collects medical information from a patient's specialists
    • Puts patients in touch with support groups, disease information classes and other services, as needed

    The care coordinator also works with your PCP to contact patients when they are due for vital health care services, such as mammograms, colonoscopies or comprehensive annual exams.

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  • No. Special training and a specific type of care are required to be a designated medical home practice. All USMD PCPs are, however, part of a medical home.
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  • One of the roles of medical home is to anticipate the special needs of a patient. The practice provides accommodations for special needs, such as translation services or services for the disabled.
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  • Disclosure of your race or ethnicity is voluntary. However, we highly encourage you to provide us with this information.

    Medical research has shown that individuals of particular racial or ethnic backgrounds have a greater risk of developing certain diseases and may benefit from special medical screenings, preventive care and treatments. Providing this information is optional, but can lead to a better outcome in your health care.

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  • A pivotal standard in the medical home is to adjust the program to best suit to the needs of patients and constantly improve the care received. At USMD, our goal is to provide you with the best care possible. Please help us improve by telling us how we are doing.
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  • USMD is happy to help you transfer your medical records to our system. To do this, please complete the Authorization to Release Medical Information TO USMD Physician Services form.

    When possible, please provide your USMD PCP's office with a point of contact from your previous providers' office, as this helps facilitate the transfer of care. Return the completed form to your current physician's office and they will handle the transfer of your records to USMD.

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  • Being part of USMD's medical home is not insurance based. At USMD, equal access to the medical home is available regardless of insurance status or insurance providers.

    If you do not have insurance or need additional assistance, USMD has social workers and care management teams who can help you review and understand programs that may be available to you. Please let your PCP's office know if you would like to speak with a USMD social worker or a member of the care management team.

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  • All patients who see a USMD PCP are part of our medical home. To get the most out of your participation, please follow your PCP's care plan, including receiving follow-up care and therapies, as prescribed.

    In addition, please let your PCP know if you have difficulty affording medications—he/she may be able to help. Call your PCP if you are admitted to a hospital and/or have visited an Emergency Room and let him/her know if you are seeing a specialist. You should also sign up for NextMD, USMD's secure, password-protected internet portal.

    Most important, if you feel you have an urgent problem or minor emergency, please call your USMD clinic first. Even after hours or on weekends, someone is available 24 hours a day, seven days a week to help you.

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USMD provides equal access to all patients, regardless of the patient's source of payment. We appreciate the cooperation of all patients to ensure each patient has a healthier and happier future.