PCMH

The Patient-Centered Medical Home & You:
Frequently Asked Questions (FAQ) for Patients and Families

What is a Patient-Centered Medical Home?

A Medical Home is all about you. Caring about you is the most important job of your Patient Centered Medical Home. In this personal model of health care, your primary care provider leads a team of health care professionals that collectively take responsibility for your care.  They make sure you get the care you need in wellness and illness to heal your body, mind and spirit.

Your personal provider and an extended team of health professionals build a relationship in which they know you, your family situation, your medical history and health issues. In turn, you come to trust and rely on them for expert, evidence-based health care answers that are suited entirely to you or to your family.

How will a Medical Home lead to better care for me?

There are many benefits to being in a Medical Home:

  • Comprehensive care means your medical home helps you address any health issue at any given stage of your life
  • Coordination of care occurs when any combination of services you and your provider decide you need are connected and ordered in a rational way, including the use of resources in your community
  • Continuous care occurs over time and you can expect continuity in accurate, effective and timely communication from any member of your health care team.
  • Accessible care allows you to initiate the interaction you need for any health issue with a physician or other team member through your desired method (office visit, phone call, or electronically) and you can expect elimination of barriers to the access of care and instructions on obtaining care during and after hours.
  • Proactive care ensures you and your provider will build a care plan to address your health care goals to keep you well, plus be available for you when you get sick.
  • Evidence based care means that your care team keeps up to date with the latest medical research and clinical practice guidelines, and will work with you to personalize your care to fit your preferences and your goals.

Who is my Medical Home Team?

Your team may include a doctor, nurse , licensed practice nurse, medical assistant , as well as other health professionals. These professionals work together to help you get healthy, stay healthy, and get the care and services that are right for you. When needed, your personal doctor arranges for appropriate care with qualified specialists.

What does my Medical Home Team do for me?

The Medical Home team is your team. They provide you with the care you need, when you need it and customize your care to meet your needs and expectations. We help you set appropriate health goals and work with you to meet them. We will spend enough time with you to ensure you understand what you need to do to successfully meet your goals and answer any questions you might have. We help you understand all your options for care so you can decide what care is best for you. And we will always treat you with the respect you deserve as a full partner in your healthcare.

What type of services does my Medical Home provide for me?

We provide comprehensive, compassionate and continuous care for people of all ages.

  • Same day appointments
  • Preventive care and physicals (health risk assessments, sports and school physicals)
  • Chronic disease management (such as diabetes, heart disease, arthritis, asthma and more)
  • Acute care for illness and injuries
  • Well child visits, screening and vaccinations
  • Well woman exams
  • Group visits and classes to help you lead a healthy lifestyle
  • 24×7 phone access to your care team
  • Online electronic access to your medical records
  • Referrals to vetted specialists and mental health providers
  • Management of multi-specialty care plans including mental health

Will my Medical Home help me take care of myself?

The care you receive in a Medical Home goes beyond the office visit with your personal clinician.

  • We want to make sure you develop a clear idea of how to care for yourself.
  • We want to help you set goals for your care and help you meet your goals one step at a time
  • We want to encourage you to fully participate in recommended preventive screenings and services
  • We will recommend tools and education materials you can use to improve your condition and manage your health
  • We will give you information about classes, support groups, or other types of services to help you learn more about your condition and stay healthy
  • We will provide you with information about resources in your community to help you manage your health and your wellbeing
  • We will provide you with resources and, if needed, appropriate referrals to behavioral health specialists to help you make and sustain healthy changes to lifestyle or to address mental health conditions for you and other family members

How can my Medical Home help if I need to see specialists or go to a hospital?

Your medical home team will coordinate your care with all your other health care providers. They will recommend quality specialists for you and your family and will work with your specialist and the hospital to continuously plan and manage your care.

With your consent, your medical home team will inform specialists and hospitals about your medical conditions, your preferences and your goals and will follow up to obtain information after your specialty visit or your hospital stay. We will also follow up with you and your family to make sure your get the care you need and that you understand your plan of care.

Can my Medical Home help me when I have an emergency?

If you have a medical emergency, please dial 9-1-1.

For other clinical problems or medical advice, call your Medical Home first. Depending on the nature of the problem, we may be able to save you an expensive and inconvenient trip to the emergency room for problems best addressed by your personal primary care provider. You can reach a Medical Home team member via telephone 24×7, and same day appointments are always available.

If you do go to the emergency room, please make sure you let the staff know who your primary care provider is and ask that they contact your Medical Home as soon as possible so we can help them take better care of you and your family.

What can I do to help my Medical Home team take better care of me?

You are encouraged to actively participate in your care.

  • Understand that you are a full partner in your own health care
  • Learn about your condition and what you can do to stay as healthy as possible
  • As best you can, follow the care plan that you and your medical team have agreed is important for your health

Do your best to communicate with your Medical Home team

  • Tell us all about your health, your medical history and the health history of your family
  • Bring a list of questions to each appointment. Also, bring a list of any medicines, vitamins, or remedies you use.
  • If you don’t understand something your doctor or other member of your medical home team says, ask them to explain it in a different way
  • If you get care from other health professionals, always tell your medical home team so they can help coordinate for the best care possible
  • Talk openly with your care team about your experience in getting care from the medical home so they can keep making your care better.

How do I access my Medical Home?

We offer convenient same-day and next-day appointments, after-hours phone access and extended hours including Saturdays and Sundays

Monday,                     8:00 AM – 5:00 PM

Tuesday                      8:00 AM – 5:30 PM
Wednesday                8:00 AM – 5:00pm
Thursday                    8:00 AM – 6:00 PM
Friday                         8:00 AM – 5:00 PM
Saturday                     8:30 AM – 12:00 PM for Urgent Care

Sunday                       8:30 AM – 12:00 PM for Urgent Care

To make an appointment, call 727-525-2161

For clinical advice and all other matters, please call  727-525-2161. We respond in a timely manner to your phone calls or electronic messages sent through the Patient Portal.

For all urgent matters, please contact us by phone. For all non-urgent matters, general information and to make an appointment, please call us during normal business hours.

How do I transfer my records to my Medical Home?

We will need your consent to obtain your medical records from your previous primary care provider or from specialists you have seen in the past. Consent forms are available from our office.

You can also call our front desk during business hours if you need extra copies sent to you, or ask our staff for assistance on the phone or when you visit with us.

 

Can I be in a Medical Home if I don’t have health insurance?

We accept many insurance plans and in some cases cash patients. Call us to discuss your particular situation. Once you become a patient in our practice, we provide you with the same access and care regardless of your health insurance status.

For more information and useful tools to check your eligibility visit Healthcare.gov or ask one of your care team members for assistance.

Who is my Medical Home Team?
Your team may include a doctor, nurse , licensed practice nurse, medical assistant , as well as other health professionals. These professionals work together to help you get healthy, stay healthy, and get the care and services that are right for you. When needed, your personal doctor arranges for appropriate care with qualified specialists.


STEPHEN G. NELSON, MD., PA 1/10/2019

PCMH 1: Team-Based Care and Practice Organization.
Competency C: Patient Communication and Engagement

TC09: Role of the Medical Home

The Practice orients new patients, and has a process and materials that it provides patients, families and caregivers on the role of the medical home.

Procedure

The Practice provides patients, families and caregivers information on the obligations of the medical home, as well as the responsibilities of the patient, family and caregiver as partners in care. Specific services that patients can expect from the Practice, whom to contact for specific concerns, questions and information, and the roles of the care team, are explained to patients and families. The Practice provides the information in multiple formats to accommodate patient preference and language needs.

The information provided to patients, families and caregivers includes, but is not limited to:

  • Goals: A concise statement of the principles of the patient-centered medical home and the Practice’s intended role to care for and coordinate the range of the patient’s care across all settings.

 Our goal is to be your partner in health care by serving as your medical home. We are committed to make available to you a personal physician who provides for all of your health care needs and coordinates your care across all settings, including the medical office, hospital, clinics, behavioral health, testing facilities and other places where you receive health care.

  • Access: The Practice’s office hours, telephone numbers, where to seek after-hours care, and how to communicate with and request clinical advice after office hours.

You may request care and advice by calling 727-525-2161 during or after office hours.  You may call 727-525-2161 24/7.

The Practice provides equal access for all patients, regardless of insurance status. Equal access regardless of insurance status is stated in the material.

  • Expectations: A description of the comprehensive patient information the Practice needs from the patient and patient’s previous and other current providers to effectively serve as the patient’s medical home. At a minimum, this information includes current medications, allergies, visits to specialists, medical history, health status, behavioral health care, recent test results, self-care information and data (or where to obtain it) from recent hospitalizations, specialty care or emergency department visits.

We expect you to provide us with your medical history, as well as information about any care you obtain outside of our Practice to include your current medications, recent test results, visits to other doctors and health care providers, behavioral health services, hospitalizations, and emergency department visits.

Quality Control

The Practice monitors the policy and procedure in the following manner:

  • Annual monitoring of the percentage of new patients receiving an orientation with the Practice’s medical home statements of goals, access and expectations.
  • Information about office hours, telephone numbers and contacts is updated on the Practice’s website within 24 hours of any changes to these data.
  • Printed patient information materials about the Practice’s medical home goals, etc., are kept updated and addendums or revised statements are re-printed and mailed and/or electronically transmitted via a patient portal or website notification to patients when major changes occur.