FORT LEE, Va. (May 15, 2012) -- For the past 15 months, Kenner Army Health Clinic has put a lot of time, energy and commitment into incorporating the patient-centered medical home at Fort Lee. The focus of this initiative reflects Kenner's belief that the patient is an integral part to the success of the patient-centered medical home.

"The traditional delivery of medical care is reactive after a problem occurs. PCMH is a proactive model of health care delivery to reduce occurrences of injury and disease," said Lt. Col. Martin Doperak, deputy commander for Clinical Services at KAHC.

PCMH represents a new approach to delivering patient care. It promotes continuity of care by creating a partnership between patients, their Families and care providers using a centralized, comprehensive electronic record of the individual's health information and services provided.

The PCMH is one of the new and exciting things KAHC is pursuing to ensure patients and their provider teams have an ongoing relationship that doesn't depend solely on sporadic or intermittent care.

The four critical aspects of the PCMH follow:

Increases continuity of care with your primary care manager and care team

Most patients think about their health care only when they have an upcoming appointment or when they experience health concerns.

The PCMH concept also delivers coordinated care over a long-term relationship, particularly for individuals suffering from chronic conditions such as diabetes, asthma, hypertension or heart disease. The PCMH portal provides a mechanism to allow patients to track these conditions much more routinely and aggressively with a provider's oversight on a regular basis.

Introduces the concept of a care team

In order to handle the increased frequency of interaction, the provider will need help managing patient care on a regular basis. The PCMH philosophy allows for the distribution of care to a patient care team that includes the provider, the nurse working directly with the provider, the care coordinator and the front desk staff.

As part of the Patient Care Team, the care coordinator (a clinic registered nurse) helps manage routine monitoring and communication, with each team member assisting the patient and off-loading tasks of the provider.

Coordinates chronic and preventative care based on national guidelines

High risk patients will regularly provide information through the patient care team when information is out of an acceptable range, or in some cases, if patients have failed to submit information on the expected schedule.

The ability to monitor patient data over time -- routine information that physicians have not previously had access to -- allows immediate intervention should high risk conditions get out of control, or should low risk conditions begin to worsen. PCMH is the tool that allows both providers and patients to track and monitor the data over time.

Coordination of care visible to the patient

Many times, patients have little understanding of why they're being asked to follow certain treatments or instructions.

When the entire care team -- from primary care physician to specialist to care coordinator -- helps deliver care and translate information into words the patient can understand, the reasons become clearer to the patient, leading to better compliance and outcomes. The patient becomes a partner in the decision-making process.

"Kenner believes that PCMH will be a welcomed change to health care and the Fort Lee community, said Col. Joseph S. Pina, KAHC commander. "Because PCMH is a cultural change in the delivery of patient care, it is still a work in progress; it will be two to three years before PCMH will be fully implemented at the clinic."

Page last updated Fri May 18th, 2012 at 00:00