A Patient-Centered Medical Home is a health care network that provides high-quality, cost-effective primary health care. Care is coordinated through your primary care provider (PCP) in a timely manner. As a Patient-Centered Medical Home, PCC provides care based on current research recommendations. Our providers give you the support you need to meet your health goals so you can feel at your best.
By setting clear clinical goals, PCC can constantly strive to improve health outcomes for our patients. Simultaneously, we will continue to provide patient-centered care to ensure that individual patient needs are assessed and met. Through team-based care, an integrated care model, and an extensive support staff, PCC can support the many needs of patients and expand programming in a meaningful and effective manner.
Team-based care is a collaborative method of staff working together in the clinic in order to best serve each patient. Teams include medical providers such as family medicine physicians, certified nurse-midwives, and advanced practice nurses. They also include nurses, medical assistants, patient care representatives, care coordinators, and clinical care managers.
In some of our larger health centers, we have multiple teams. You will be working with a team to ensure that you receive care from providers and staff who get to know you each time you come in. If you have questions about your care team, you can ask your provider for more information.
Care management is the collaborative process of conducting health assessments, care planning, facilitation, care coordination, ongoing evaluation, and advocacy. These activities help PCC communicate options and provide comprehensive health services for individuals and families.
PCC’s Care Management Program focuses on the health of each patient while making sure that overall, communities begin to become healthier. Our Care Management Team includes care coordinators and clinical care managers that serve as a bridge between PCC, hospitals, and other community organizations. Care coordinators and clinical care managers are partners in patient care. They will be part of your care team.
Care coordinators serve as outreach workers and provide additional services to patients. They can share health information with patients, share resources, help with referral coordination, and follow up between appointments. Care coordinators have certifications as community health workers or experience in the community health center field.
Clinical care managers are either licensed clinical social workers or registered nurses. They work with care coordinators to offer additional patient assistance. For example, they may help patients understand their care plans, review prescriptions, or order home health equipment.
PCC believes in the importance of self-motivation in reaching health goals. For this reason, providers regularly discuss patient-defined goals during clinic visits and keep track to ensure follow-up and regular reassessment. The care team works with patients to to holistically address goals and spark motivation and change. Examples of potential self-management goals are attending scheduled appointments, taking medication daily, reducing the number of cigarettes each day, or making efforts to lose 1-2 pounds each week.
Electronic Health Records
PCC uses an electronic health record (EHR) to maintain and track patient health care data. PCC transitioned to a new platform by athenahealth in the fall of 2017. Our new system will make patients’ lives easier while receiving high-quality health care.
Automated messaging with reminders about appointments, recommended preventative and follow-up care, and bills
Live operators to help cancel or reschedule appointments, pay bills, and leave messages for the care team