A basic tenet of the patient-centered medical home model is changing episodic, acute-focused care to a model that promotes wellness and helps each patient be at their highest level of health. For some, this means discovering risk factors, reminding them to get flu shots, and encouraging preventive screenings. These patients have taken time to become educated about health and what it takes to stay well.
Other patients are already suffering from a chronic disease such as diabetes. Their HbA1c level fluctuates in and out of the desired range, they’re 30+ pounds over goal weight, and they’re complaining that orthopedic issues keep them from exercising. This is the type of patient that will benefit most from a team-based approach.
This is a high-risk, high-utilization patient who probably makes a number of emergency department visits each year in addition to your care. A team-based approach includes pro-active care starting with pre-visit planning to ensure lab work is ready for the primary care provider when the patient arrives. Follow up by other team members is essential to ensure medication compliance and nutritional/fitness improvements. The goal is to keep this patient from developing disease complications and achieve the highest level of wellness they can.
Is it worth it? You bet. When the workload is shared among team members, everyone benefits; most of all the patient. And, isn’t that what medicine is all about?