Patient-Centered Medical Home

Patient-Centered Medical Home

In order to provide the best patient care possible, Clinica Sierra Vista has paired each patient with a specific provider. This allows the provider and the patient to work together as a team to solve health related issues. How? By seeing the same provider over the course of time the provider has the opportunity to become familiar with your medical history. This allows the provider to have tremendous insight into what may be going on with you and have a better path to treatment and maybe even prevention.

What is a medical home?

The patient-centered medical home is a model for care provided by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship.

Effective & Comprehensive Primary Care is Based on Four Cardinal Features:

  • "I can get care when and how I need it"
  • "I have a PCP (primary care provider) who knows me as a person"
  • "My PCP takes care of the bulk of my health care needs"
  • "My PCP coordinates all my care"

Listening to our patients is a top priority for Clinica Sierra Vista. The cornerstone of patient-centered care is superb communication. If you are a current patient we value your health and your ideas.

Treating organ system or treating people? The paradigm of measuring quality by organ system and bio metric is based on the notion that overall quality of care is the sum of the parts and that humans are sums of organ systems. This is a demonstrably false notion that leads us down into the weeds of measurement. This path is very seductive because of the obvious logic behind the micrometric: If having a mammogram is a good thing, then counting the percent of mammography is a good thing and is a good indicator of quality of care.

The problem with this path is the lack of replicability outside the research environment. In the real world of primary care we manage patients with multiple conditions, multiple mixed motivation, multiple needs. Nailing the perfect guideline driven care for one system often creates unintended consequences for another evidence based intervention.

Take diabetes and depression. 40% of people with diabetes have depression. The guideline for diabetes care instructs patients to get a glucometer and check, document & report readings regularly. Ignoring for a minute the lack of evidence that this intervention works for Type II DM, there are some recent studies that tell us the results tend to increase depression in patients with diabetes. We know that treating depression helps patients with diabetes do a better job of managing their diabetes (linked to more exercise, losing weight and all sorts of good things linked to better outcomes). Depression is bad for diabetes outcomes but is a consequence for some patients who strictly adhere to the guideline. Guideline A is in direct conflict with Guideline B.

What’s the best course for managing diabetes and depression? Only the patient and the provider can know the answer.

Shared decision making and patient choice: Really good studies tell us that we can increase the probability of our patients following through with certain things (mammography, colorectal cancer screening, smoking cessation, etc) if we work with them in a certain way. We can help more people achieve better clinical outcomes when we take the time to listen and have learned certain skills around shared decision making, motivational interviewing, self-management support, and when we have the resources to engage in follow-up.

We need a different system of measurement. Comprehensive primary care is not the sum of disease management bio metrics. We work in the real world of complexity, ambiguity, mixed incentives, mixed patient motivation.