Primary Care Medical Home (PCMH) is a model of care that empowers patients and is transforming how primary care is organized and delivered. PCMH can best be described as a team-based healthcare delivery model led by a healthcare provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal health outcomes. However, since the onset of the coronavirus, healthcare systems, including Primary Health Network (PHN), have been greatly impacted. To minimize the spread of infection, PHN was forced to properly mitigate the use of services and place heavy restrictions on face-to-face care. PHN executives and staff alike raced against time to install advanced approaches to care that would ensure patients’ needs were being met. Among those programs includes the ENHANCED Primary Care Medical Home program (EPCMH).
The EPCMH program is made up of a team of nurses who are providing proactive outreach to high risk or vulnerable patient populations. The concept of the program is to minimize delays in scheduling patients who are most in need. Patients are assured that their care is being met and are also screened for socioeconomic barriers and other potential health risks, such as behavioral health needs. If patients are in need of care and screen positive, various internal and external referral systems have been devised. Stephanie Hansley, Primary Health Network’s Case Management Supervisor, states, “Our communication is simple yet concrete. We provide information to the patient regarding continued care via EPCMH Telehealth through the current Covid-19 pandemic. We also let the patient know that although the stay at home order is in place, their provider can still partner with them (the patient) to manage their care, provide refills, and coordination of specialty care. They are then scheduled for an appointment with their preferred PHN provider via telehealth. If screened positive for socioeconomic needs, the patient is then sent to PHN’s Patient Experience department for additional assistance.” Stephanie goes on to describe her experience thus far with the program:
“The reception from many patients has been incredible, supportive, and positive. I have had numerous compliments towards PHN regarding outreach and offering the EPCMH Telehealth Visits. An example that comes to mind is of a patient who explained that they were overjoyed to receive a call. They had been home for so long and didn’t know what to do and were in need overdue lab-work. I listened for quite a while, provided key answers to the patient’s questions-documented for the provider, scheduled the visit, and informed the patient to call the PHN Site with ANY additional concerns. As we ended the call, I could sense the patient was relieved to know their needs were being taken care of. It has been a fulfilling experience working and helping those in need.”
To learn more on EPCMH, please visit the Primary Care Medical Home section of our website.