Alicia Jacobs, MD is the medical director of Colchester Family Practice, which is a certified medical home, working in collaboration with Milton, South Burlington and Hinesburg Family Practices. Dr. Jacobs is also associate professor of Family Medicine at the Larner College of Medicine at UVM.

What is a Patient-Centered Medical Home (PCMH)?

A PCMH is a medical office that that is organized to use specialized health teams and in-office processes to improve access, comprehensiveness, and quality of care for the patients they serve.  In other words, it is a primary care office that is organized to create thorough, excellent, on-time care. Patient-centered medical homes have been certified by an organization (NCQA) dedicated to ensuring high-quality medical care.  All of the UVM Medical Center’s primary care sites are recognized medical homes.

How does a Medical Home Benefit me as a Patient?

  • Medical homes work in partnership with you to provide high-quality patient care that is tailored just for you
  • Medical homes provide a team approach to better coordinate your care and improve communication among all of your care providers. Using teams to provide care also ensures that your primary care provider can focus their time with you exclusively on your health concerns
  • Medical homes emphasize preventive care, to keep you healthy and reduce your risk for developing a chronic disease.
  • We’ll keep track of what tests you need and what medications you’re taking, and work with you before, during and after your visits to extend your care beyond our clinic walls.
  • Our Care Teams and the use of electronic health records save you time and effort in filling out paperwork, scheduling appointments, and navigating the health care system
  • A medical home is designed to improve access for all patients
  • Medical homes focus on the whole person, not just physical illness, by facilitating a seamless patient experience across the care continuum, from primary care to specialty care, mental health counseling to diet and nutrition –connecting you with medical and community resources that contribute to your physical and mental well-being
  • Medical homes are dedicated to quality care in a way that improves the health of the entire community

Why use the word ‘home’?

The medical home is the “home base” for all the care patients need.  Not only do our providers work with patients’ other medical specialists and community support services, we also have added many new services in our office that make it easier to have tests and assessments available in one place.  Our Care Teams now include the members of a Community Health Team.

How does the Community Health Team work with my provider?

Community Health Teams are part of your Care Team.  They provide coordinated care in the primary care office and complement the traditional work of a physician, nurse practitioner or physician assistant.  These professionals – health educators, dietitians, social workers, nurses – can work with you on specific issues and connect you with additional resources in the community to help you achieve maximum wellness.

How will Medical Homes improve health care in general?

Besides improved access and a focus on whole person health assessments, medical homes have a systemic approach to improving the overall quality of health care delivery.  Some quality initiatives are simple.  For instance, a medical home can strive to increase flu vaccination rates in order to decrease illness in susceptible populations.  Other quality improvements topics are more complex, such as how to improve already good chronic health management to make it even better.   For example, the coordinated medical team can set goals for the whole team, like creating a seamless process for transitions in and out of the hospital, using a health coach to help diabetics make some healthier eating choices, or checking the breathing status of a person with asthma or emphysema.

This sounds expensive.

Medical Homes are dedicated to spending health care dollars wisely.  Coordination and tracking reduces duplication and unnecessary procedures.  Providing preventive care and wellness counseling up front is far more cost-effective than treating medical emergencies. This is particularly true for people who have chronic illnesses.

How will this affect my care?

The ultimate goal is improved health, wellness and well-being.  The more proactive and engaged we all are in our own health, the better the outcome.

Alicia Jacobs, MD, family medicine physician, is Vice Chair of Clinical Operations in Family Medicine at The University of Vermont Medical Center. She is also practices at Family Medicine Colchester.



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