Demystifying the Medical Home: A Practical Guide for Patients
By Cindy Green, Emtiro Health Practice Optimization Manager
The healthcare industry is notorious for its acronyms and jargon. As a patient, navigating this space not only requires a great deal of patience but also a glossary of industry terminology and buzzwords. The purpose of this article is to introduce one such medical term that is a central tenet in care delivery innovations and transformation: The Medical Home.
It is likely that most readers have been a patient in a medical practice at some point in life, whether for themselves or with a child or parent. As for myself, in caring for my aging mother I have come to realize that patients like her (as well as many others) may not fully understand the benefits of belonging to a Medical Home. In fact, when asked for her definition of a Medical Home, my mother replied simply, “It’s a home where people can go to receive medical care.”
Upon further questioning, I quickly recognized her challenge in articulating with any confidence what the term really meant to her and what she should expect as a patient receiving care in this setting.
I suspect that my mother is not alone in her lack of clarity on this subject. At Emtiro Health, we believe in empowering patients with the knowledge necessary to confidently navigate their health care. As such, let’s begin by breaking down what a Medical Home is, both in general and in applicable terms for patients.
What exactly is a Medical Home?
The term “Medical Home” was first introduced by the American Academy of Pediatrics in 1967. At that point, its focus was the creation of a single source of medical information in the care of children with complex diseases. Over the ensuing decades, the concept has broadened in both application and scope.
In collaboration with other founding members of primary care delivery transformation, the Agency for Healthcare Research and Quality (AHRQ) describes a medical home as a model or philosophy that organizes primary care around five core functions and attributes which allow primary care to achieve its potential. These five core functions or attributes are:
Comprehensive Care,
Patient-Centered Care,
Coordinated Care,
Accessible Services, and
Quality and Safety.
But simply put, a Medical Home is about you, the patient. Caring about and for you is the most important job of a Medical Home. As such, it is the care team’s job to make sure that you get the personal and individualized care that you deserve.
Within a Medical Home, a care team surrounds each patient and may include a Provider (Doctor, Nurse Practitioner, Physician Assistant, etc.), Clinical Support Staff (Nurse, Certified Medical Assistant, etc.), Health Educator, or several other varieties of health care professionals such as Community Health Workers or Pharmacists. Caregivers are also included as part of this team, as healthcare providers recognize the critical role they can play in a patient’s health. These team members are like having “health coaches” to guide patients in setting, achieving, and maintaining health goals through care planning and regular assessment. Ultimately though, you, as the patient are the most central member of the team.
What a Medical Home means for YOU (the Patient)
As patient-centered entities, Medical Homes offer myriad benefits to the patients they serve, including, but not limited to:
24/7 office access, providing quick clinical advice during and after office hours and offering same-day appointments where indicated.
Whole person care, not just treating a patient for one isolated illness or condition. The team considers the whole person comprehensively, to help work towards a healthy lifestyle by providing prevention/wellness visits, treatment for both physical and mental health issues, and self-management planning to help patients succeed in reaching goals.
Teamwork, internally among the care team but also externally as providers collaborate with other specialists involved in a patient’s care.
Coordination, to ensure timely responses from lab results, imaging orders, or other referrals, and also in reconciling and recording medications received from other facilities or providers, to uphold patient safety.
Technology, to help the Medical Home stay up-to-date by sending reminders to patients for wellness visits, testing, and upcoming appointments. Technology also offers a way to communicate virtually with the Medical Home team in order to schedule visits, request prescription refills, receive test results, and access your personal health record.
Absent these cornerstones, primary care becomes disconnected and often siloed, underserving patients and ultimately negatively affecting health status.
What Your Care Team Should Do for YOU
By now, the benefits of establishing as a patient in a Medical Home should be clear. However, to take full advantage of these benefits, patients are responsible for being an active participant in their care team by holding their team accountable. At minimum, patients should look for their care team to:
Learn About You – In order to paint a full picture of health, a patient’s team should gather details about health history, family, social history, and preferences for receiving care. These details should be documented in your chart so that they may be available and recollected at each subsequent visit. These details should also be referenced when suggesting treatments that make sense for you, specifically.
Communicate with You – Your team should give you ample time to ask questions and should answer those questions in a way that you understand. Always bring a list of questions to each appointment along with a list of any medicines, vitamins, or remedies that you currently take. It is the care team’s job to make sure that you know and understand all of your options for care and to help you decide what care is best for you. Never be ashamed to tell the team when something isn’t clear and ask to explain it in a different way. Also, be willing to openly share feedback regarding your experience.
Support You in Caring for Yourself - As a full partner in your own care, you should learn about your condition and what you can do to care for yourself in order to stay as healthy as possible. As best you can, follow the plan that you and your Medical Home team have agreed upon. And if you have questions, ask! Make sure you leave the office with a clear idea of how to care for yourself. Your team should help you set goals for your care and empower you to meet your goals one step at a time. They should offer you information about classes, support groups, or other types of services that can help you become more empowered about your condition.
The Medical Home model supports practice functions and philosophies that promote high quality care through trusting relationships among families, patients, clinicians, and the community. Research shows that, patients cared for by Medical Homes are less likely to visit the Emergency Room. Generally, these patients also require less hospital care because the care they receive is well-coordinated. In short, Medical Homes offer a great value for everyone involved.
In summary, joining a Medical Home offers patients a more intimate relationship with their care team, with the patient activated to play a larger role in directing their own health. As discussed, the first step in this engagement is understanding the provisions included in the Medical Home, and that providers and patients alike make contributions to the success of this model. At the core, providers and care teams must attempt to convey easily comprehensible information to patients, while patients must let providers and care teams know when they have questions.