One year after Iredell Health System’s Family Care Center of Taylorsville set the benchmark by achieving Patient-Centered Medical Home (PCMH) recognition, eight more of the Health System’s practices achieved PCMH status and were recognized for serving patients with the new model of patient-centered care.
Using the non-traditional approach to achieve care-coordination on behalf of each patient, Iredell Health System practices provide comprehensive care through a network of primary care providers and specialists.
As part of their emphasis on access of care, the practices set aside same-day appointment slots for pressing needs. Their patient-centered approach revolves around pre-visit planning and quality metrics.
Accountable to their patients and committed to their patient-centered healthcare model, the practices will continue an annual reporting cycle to maintain their PCMH status.
Carla Johnson, director of operations for the Iredell Physician Network, emphasized ways providers fill gaps in their patients’ care:
“You left as a patient and we referred you to a specialist – we want to know, did we receive your notes? Did you get an appointment? Did you go to the appointment? Did we get your results? Did we follow up after that? We’ve really fine-tuned our machine,” she said.
Traditionally when patients see their primary care providers and different specialists, each has their own regimen of treatments and medications with less regard for how those treatments interact. In a PCMH, all patient information flows to and from each provider. So, each provider knows the full picture of the patient before they walk in the door.
“If you think of a circle, we’re all pivoted around the patient, versus the patient having to go all different directions,” Johnson said. “A PCMH is doing all the leg work so the patient doesn’t have to.”
Ensuring their patients access of care, Iredell practices set aside same-day appointment times for pressing needs. Johnson emphasized the importance of families knowing they can call their practice and get in the day something happens.
“Instead of going through the day seeing if the patient fits into our schedule, we try to fit into the patient’s schedule,” she said.
Contrary to the traditional healthcare model in which offices plug their calendars full of appointments day after day, Iredell Health System practices keep continual openings each day.
The practices review details on patients before they come in for visits.
Employees huddle each morning to review scheduled appointments and address patient needs such as a wheelchair or language-interpreter.
The practices make sure they have the results from providers the patient has seen since their last visit. They review details from previous visits and follow-up on details, making any appointments the patient needs them to make.
After an Iredell primary care provider refers a patient to a specialist, they view whether the patient visited the specialist. They then obtain a report of the visit.
“Just as the specialist expects us to send all the background preliminary information to help them understand why they’re there, we need to understand what the outcome was,” Johnson said.
“It helps the patient because before, a patient may come back and be asked if they went to the specialist we referred them to, but if the specialist’s office had never called, we never would have known that. Now, we have a tracking system implemented in every practice to close that gap. If you’re having issues getting in to see a specialist, that’s probably not a specialist we’ll refer you to again.”
Johnson explained the value of pursuing PCMH status.
“It allowed us the capability to reassess all our workflow processes to make sure we were 100 percent in every area.”
Backed by the National Committee for Quality Assurance (NCQA), Iredell Health System practices will make their PCMH-status their standard and their patients’ expectation moving forward.
“NCQA Patient-Centered Medical Home Recognition raises the bar in defining high-quality care by emphasizing access, health information technology and coordinated care focused on patients,” NCQA President Margaret E. O’Kane said. “Recognition shows that Iredell Health System practices have the tools, systems, and resources to provide their patients with the right care at the right time.”
For the eight newly recognized practices to earn PCMH recognition, Johnson submitted 587 evidences to the NCQA for review in 2019. However, Iredell Health System doesn’t consider its PCMH status just a series of guidelines but rather a model which helps its physicians develop meaningful relationships with their patients. Physicians interact with patients to learn their needs such as whether patients have access to medication, adequate transportation, and heat in their home.
The PCMH recognition shows Iredell Health System’s value in remaining a high-performing, leading network of practices in a new era of proactive, patient-centered healthcare.
Pictured: Office managers from the nine PCMH-recognized practices. From left to right: Julie Mooney, Iredell Primary Care for Women; Jenny Turrentine, Family Care Center of Mocksville; Kellie Dancy, Family Care Center of Taylorsville; Elaine Leviner, Iredell Internal Medicine; Christy Estes, Statesville Family Practice; Susan Pope, Nicholson Internal Medicine; Elizabeth Jacinto, Harmony Medical Care; and D'Asya Cooper, Iredell Family Medicine. Not pictured is Kelly Johnson, Tondo Internal Medicine.