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Patient Centered Medical Home

What is a Patient-Centered Medical Home?

A Patient-Centered Medical Home is a model that places the patient at the center of care. A care team is composed of a primary care provider, disease manager, registered nurse, health coach, medical assistant and patient financial representative who collectively take responsibility for your care. It is a partnership between you and your health care team that aims to improve your health by coordinating care and long-term healing. Your primary care doctor is the lead of your care team.

Who is part of the Patient-Centered Medical Home Care Team?

Health Coach

Your Health Coach will assist you with your required preventative screenings and provide community resources to ensure that all of your needs are met. The will help you with MyChart activation.

Medical Home Provider

Your Medical Home Provider will evaluate and treat your medical conditions. Your provider is committed to providing the highest quality of care.

RN Coordinator

Your RN Coordinator will assist you wil understanding how to manage your health when you have diabetes, high blood pressure and heart and lung conditions.

Disease Management Nurse

Your Disease Management Nurse will provide education to you about diet, exercise and medications to help you to control diabetes, high blood pressure and heart and lung condtions.

Patient Financial Representative

Your Patient Financial Representative will assist you with checking in and out during your office visit. They will schedule your next lab and provider appointment at discharge. They also will assist you with referrals to specialists.

Medical Assistant

Your Medical Assistant will assist you with updating your health information, medications and prepare you for your visit with your provider. Your Medical Assistant will explain your discharge instructions to you and ensure that you know your plan of care.

How Does a Patient Centered Medical Home Benefit Me?

  • You can contact the healthcare team around the clock, either by telephone or via Memorial My Chart, which allows you secure access to your medical records
  • Your care team will help you understand your health conditions, and how to take care of yourself. We will explain information in a way that you can understand and make decisions about your care
  • Your care team will help you coordinate your care with specialists, self-care support, and community resources
  • Your care team will help you set goals and assist you to meet your goals

How you can contribute

  • Take charge of your health by learning about preventative and chronic care management
  • Participate in your care by keeping your appointment, taking medications as instructed, and ask questions when you do not know or understand something
  • Communicate with your care team and ask questions about your care when you do not understand. Inform your care team, if another provider that is not your primary care provider has seen you. Inform us about any changes in your health