“What did you welcome me to? “ A Medical Home!  What’s that?  Actually, this is not a new idea. The American Academy of Pediatrics (AAP) introduced the concept over thirty years ago, but in the past five years, the American Academy of Family Practice and the American College of Physicians (internal medicine) have joined the AAP in promoting the concept.   Your medical home at SETMA has been recognized by the National Committee for Quality Assurance (NCQA), from which SEMTA has received the highest award which is a Tier Three.  It is also accredited by the Accreditation Association for Ambulatory Health Care.  Very few organizations have more than one accreditation.  Two other agencies accredit medical home: URAC and the Joint Commission.  In 2012, SETMA will seek accreditation by both.

The goal of medical home is to bring you better medical care.  A Medical Home is not unlike your family home. It is a place where people care about you personally and where you can trust that your interests come first.  It is a place you can go when you have a need.  Like your home, a Medical Home is made up of a team, each member of which has a special role, but where no one person is more important than another. It is a place where the team makes certain that all of your needs are met.

In many ways, Medical Home is like the care you have been receiving from SETMA for years. With the use of electronics, SETMA has been able to develop systems which protect you from medical errors and which can insure that you are receiving the care you need and deserve.  Now new dimensions have been added which are the Care Coordination Team (CCT) and the Department of Care Coordination (DCC).

The CCT is a team of people who focus on your needs, whether they are ordinary, like every one else’s, or whether they are special, extraordinary needs which are unique to you.  Your Care Coordination Team will make certain that you get the care you need as they assess any barriers which prevent you from obtaining that care, whether it is financial, access, understanding, transportation or other.

The Care Coordination Team will also develop a plan to make sure that your needs are cared for in an emergency such as when a hurricane evacuation is ordered.  Medical Home is directed toward making certain that as we increase the “high tech” aspects of your quality care, we do not lose that “high touch” care we all experienced fifty or seventy-five years ago.

The CCT led by your personal physician will make certain that your care meets national standards and will share the elements of that standard with you so that you can be confident of the quality of care you are receiving..  Measured by multiple quality metric sets published by the National Quality Forum, the Physician Consortium for Performance Improvement, National

Committee for Quality Assurance, or other agency your care will be evaluated each time you come to the clinic and often at times when you don’t come to the clinic. When you have complex problems, the team will meet to discuss how to make sure that your care is optimal. Before you come for an appointment the team will review the state of your care to make certain that it meets the highest standards.

The Department of Care Coordination will be involved in your care in many special ways. If you are in the hospital, they will call you the day after you leave the hospital to make sure you have your medications and that you are clear on your treatment plan and plan of care which you received when you left the hospital.  They will also help you find the resources you need in order to achieve the maxim health possible, including helping where possible with the financial resources to meet those needs.

In your medical home, over two hundred quality standards of care will be tracked.  How your personal healthcare provider performs on these standards will be publicly reported on SETMA’s website at  www.jameslhollymd.com under Public Reporting.  One of the most common quality metric sets is published by the NCQA and is called HEDIS. More than ninety percent of America's health plans measure provider performance by HEDIS measures.  Altogether, HEDIS consists of 71 measures across 8 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance
of health plans on an "apples-to-apples" basis. Health plans also use HEDIS results themselves to see where they need to focus their improvement efforts.

SETMA has incorporated HEDIS standards into our Medical Home Care Coordination Review (MHCCR).  In addition to the LESS Initiative (Lose Weight Exercise Stop Smoking), to which you have become accustomed, and other educational materials on your medical conditions, you will receive a Medical Home Care Coordination Review (MHCCR) each time you come to the clinic.  The MHCCR will include:

• The names and contact information for your Care Coordination Team members.
• The status of your HEDIS and other quality metric sets compliance and the status of your preventive care needs.
• A list of your current medications with descriptions of your directions in plain English
• The names and numbers of emergency contacts and your medical power of attorney
• The name and number of your pharmacy as everyone who provides you care are a part of your healthcare team.
• A list of the conditions for which you are being treated.
• Information about who we are to contact in case of a mandatory evacuation so that your Medical Home can be aware if you need help in being safe.
• An assessment of any barriers to care which you have, whether they are social, financial or other.
• Any special needs you have including mobility and safety.

The MHCCR will help you take charge of your own care and for you to initiate the obtaining of the care which you need but have not received. It will allow you to judge whether you are receiving excellent care.  Of course, you will continue to receive the encouragement to stay active, stay healthy, eat right, lose weight and avoid tobacco.

Medical Home will enable you to continue to receive:

• Same day appointments for urgent problems.
• Immediate attention in the ER for emergency conditions
• Response by telephone or e-mail to your questions or concerns.
• Follow-up by telephone for your results of testing when appropriate.
• And, all the other contact you have received in the past.
• 24 hour a days, seven day a week access to a SETMA provider for your healthcare needs.

Welcome to SETMA’s Medical Home €“ welcome to YOUR Medical Home. Together, we will make your healthcare experience pleasant, satisfying, excellent and successful. Welcome to your healthcare team, of which you are not only the main focus, but now you are a dynamic and critical part.