We have been building our system of care to drive towards our vision for six years now. In 2010, we put a stake in the ground that we would become the health care system where everyone, every time, got the care we would want for our own loved ones. Our vision statement talks about physicians leading teams to deliver this. We have had a dialogue among us in the GBMC family, that we want the best health outcome and the best care experience with the least waste of time and money with the most joy for those providing the care. We chose the patient centered medical home as a design to deliver this. We already had a great hospital with excellent physicians and nurses and a great hospice, but, the medical homes were required if we were truly going to maximize people’s health and not just wait until they got really sick and needed to be admitted. Our patient-centered-medical homes are different from typical primary care because they are no longer dependent on a visit to the doctor. This model is about a relationship between a physician, her team and a patient. It is about a promise to that patient to work with him or her to maximize his or her health. It is about having the time to reflect on a patient’s health between visits, to make sure that they are getting what the evidence says will keep them well.
On a bad day, I am concerned that many people in our community don’t know how we are different or don’t believe that we are different. So let me tell you a recent story in the words of Dr. Sarah Whiteford, of Family Care Associates:
“I wanted to share this wonderful letter from a very appreciative patient whose life was quite possibly saved by the efforts of PCMH and our population health outreach. In brief, this lovely patient of mine received a call from our care coordinator, Shelly Deckelman (go Shelly!), who was going through the list of patients aged 50 and older in our practice who had not yet had a colonoscopy. This day of Shelly’s call happened to be her 50th birthday and her name clearly “fell onto the list.” She was quite surprised to receive the call but it prompted her to immediately schedule her colonoscopy (which she admitted would have likely been many months later if left to her own devices). Much to everyone’s surprise, her colonoscopy revealed a large, ominous rectal mass. She had no symptoms at all. Despite a negative initial pathology, she was sent for urgent surgery for removal of this mass as its malignant potential was quite high. Fortunately, her surgery was successful and the mass was ultimately a very high grade polyp which most certainly would have become malignant if not removed in a timely manner.”
Dr. Whiteford thanked all of her team and congratulated them for making the medical home concept a reality.
Physicians and other clinicians practicing in regular primary care are smart and care about their patients just like Dr. Whiteford and her teammates. It’s just that in regular primary care after the visit, it’s on the patient. If the patient never comes in for a visit, and they don’t know the evidence about care that can save a life, they are not likely to get that care unless someone is looking out for them. This story is one of many that shows how we are different. Without the patient centered medical home, this patient may not have had her mass found until it was too late! Let me add my thanks to all of my GBMC colleagues who are moving us closer every day to our vision.