Mission

The mission of the primary care medical home is to transform healthcare in order to achieve the Institute of Healthcare Improvement’s Triple Aim: improved care, improved outcomes and decreasing the cost of that improved care. The mission is sensitive to the fact that quality and safety of healthcare is decreased by delay in care, incompleteness of care, inconsistency of care and incomprehension of the content of care.  SETMA’s mission is to collaborate with our patients to enable them to grasp their care and to “take charge” of their own care.

Vision

The vision of the primary care medical home is for the transformation of the care received in the medical home to be:

1. A collaborative effort between all members of the healthcare team including patients, ambulatory staff, and healthcare providers (nurse practitioners, physician assistance, physicians).
2. No longer is healthcare to be delivered and/or received in a paternalistic, didactic setting. It is to be the result of a shared-decision making between patients and providers, where patients are activated with the knowledge they need in order to participate in their own care and where the  patient is engaged in adhering to the healthcare plan developed in cooperation with their healthcare provider.
3. No longer is care to be received at the convenience of office hours in the ambulatory clinic, but healthcare will be delivered and received at the time and place of greatest need. The collaboration will take place at all hours and at all locations with maximum attention given to the patient’s convenience.   
4. Continuity of care will not be driven by geography, i.e., delivered only at a provider’s office, or be personality based, i.e. only be available when a unique person is available, but continuity will be maintained as the patient’s comprehensive health record:

1. is available at all times,
2. in all places and
3. additions and/or deletions to that record will be done simultaneously at all sites in the same record at all times..

In this way, the mission vision is expanded from a primary care medical home to a medical neighborhood which spans the boundaries of type of medicine which is practiced and where all information from all providers participating in a patient’s care is simultaneously available if not through the same EHR, then through the Heath Information Exchange and/or the interoperability of different EHRs.

The Goal

The goal of SETMA’s primary care medical home is to improve the process of the care being delivered which will provide both improved experience of care and improved outcomes of healthcare, which will provide improved health to the individual and to the community, and which will reduce the cost of that care, while maintaining and improving its quality.  Ultimately, this will make the processes and outcomes of excellent care sustainable

Conclusion -- SETMA’s primary care medical home achieves the above by:

1. Using the same EHR at all sites of care: clinic, emergency department, inpatient, nursing homes, provider’s homes, etc.
2. Having medical home team member’s available 24-hours-a-day by telephone, secure web portal, encrypted testing, in person at clinic, hospital and emergency department.
3. Having expanded hours for scheduled appointments.
4. Multiple “electronic huddles” each day and night where medical home team members communicate with one another by secure e-mail, iphone and by secure, encrypted texting to discuss patient’s care and recommended treatment.  This creates a continuity of care impossible without continuous communications between different providers.
5. Clinical Systems Support which standardize care regardless of which member of the team is delivering care and/or when all members of the team are not physically available.
6. Both respecting and expecting the patient to participate in their care; respecting and committing to carrying out their end-of-life wishes, employing expanded members of the medical home team when available such as home health, physical therapy, hospice, etc.

Scope of Service

SETMA’s primary care medical home provides a list of services on our website and also discusses those services in person with the patient. Even in the case of services provided by SETMA, we respect the patient’s right to receive care in other settings even when those services are available at SETMA. For instance, when a patient needs to see an eye specialist, even though one of SETMA’s partners is a board-certified ophthalmologist with fellowship training in diabetic eye disease, if the patient has a long-standing relationship with an eye specialist and wishes to maintain that relationship, SETMA supports that decision.
Materials Given to Patients at their First Appointment Includes the following:

• An acknowledgement that the patient has the right to select and also to change their principle contact as far as a healthcare provider within the medical home.
• At each visit, shared-decision making is part of the patient-centric conversation. SETMA’s providers discuss this and continue to learn about it at our monthly training sessions for all providers from all clinics. All of SETMA’s disease management tools include “plans of care and treatment plans” and all care decisions are discussed with the patient.
• SETMA has an extensive referral tracking program which is described on our website. In addition, no referral is completed unless it has been discussed with the patient and the patient has agreed with the need for and their willingness to follow through on the referral.
• All SETMA’s care is coordinated by the provider in collaboration with SETMA’s Care Coordination Department. That is described on our website and to our patients.
• When specialty care or consultation is required, the patient participates in the decision to make the referral and in the person to whom the referral is made. In today’s healthcare culture often the patient’s greatest concern is “is that doctor in my network.” SETMA respects the right of the patent to get care from a provider covered by his/her insurance. When the patient’s preference is based on past experience, we respect that as well.

Accessing the Primary Care Medical Home

SETMA has published information about how to contact the medical home:

1. During office hours
2. After office hours
3. In emergencies
4. For questions that are not emergencies

Patient Responsibilities and Rights

SETMA has published statements of patient responsibilities and rights as they participate in the primary care medical home. The patient’s rights include the right to consultations and to second opinions.

Respecting Patent’s End-of-Life Decisions

As part of a primary care medical home, SETMA initiates decision making about end-of-life choices, code status and the making of a living will or advanced directives. SETMA works with the patient to make rational decisions when further care is futile but always respects the patient’s rights to choose decisions that which we do not agree. If, in an inpatient setting, the patient’s family or medical power of attorney wishes to pursue care which is judged as futile , SETMA goes through a compassionate, patient-centric decision making process consistent with medical ethics and hospital by-laws. At this time the primary care medical home team is expanded to include clergy, and others desired by the family. SETMA has a sample advanced- directive which is offered to patients during the discussion of end-of-life issues.  This discussion is initiated before it is needed to allow patients and families time to discuss and consider their decision.  If a patient or family is not comfortable talking about end-of-life issues, we respect that and recommend speaking to their clergyman.