PCMH - New Approach to Medical Care

EASTPORT  - A medical team approach to a patient’s health care soon will be an integral part of a new pilot program at Eastport Health Care.

Maine Quality Counts of Augusta and EHC have partnered together to bring this groundbreaking multi-year pilot project approach to Washington County.  The new focus is expected to help EHC patients from Grand Lake Stream to Jonesboro.

The pilot project known as the Patient Centered Medical Home (PCMH) is expected to improve medical care and ultimately reduce health-care costs for EHC patients. Under the new program the patient, working with a Community Care Team (CCT) that can include a doctor, nurse and health educator as well as other health-care professionals, is expected to bring individual medical care full circle as it copes with the changing dynamics of health care. 

These team members are equivalent to “health coaches” who help a patient get healthy, stay healthy, and get the care and services they need, EHC’s Chief Operations-Quality Improvement Officer Theresa Brown said. 

The PCMH approach to medical care acknowledges that some patients have needs and health care demands that are beyond the scope of their primary care physician. Through this pilot program, the team approach to health care brings an integrated support structure for high-needs patients. EHC has partnered with Aroostook Mental Health Center for community-based CCT registered nurse case management support. 

“Community Care Teams are a key element in the Patient Centered Medical Home effort to improve care and reduce avoidable costs for Maine people, especially those with complex or chronic conditions,” Maine Quality Counts said on its web site.

The major priority for the CCT is to support the patient’s whole needs.

“It is the support person, in EHC’s case a registered nurse, who will meet the patient wherever they are, literally and figuratively at home, in the community, or in the provider’s office to ensure all the patient’s needs and levels of understanding are where they need to be so the patient can more actively participate in their health care,” EHC Chief Executive Officer Holly Gartmayer-DeYoung said.

There are 75 primary care practices, in addition to EHC, from across the state that are part of the Maine Patient Centered Home Pilot Project. Funds for the project were provided by the Robert Wood Johnson Foundation. The 75 primary care practices meet quarterly in Augusta to discuss approaches to changing care delivery and to hear relevant speakers talk about their respective experiences.  

On Friday, May 31, more than 400 medical professionals and patients from across the state will be in Augusta for the fourth meeting of the pilot partners.

A primary care provider, a behavioral health provider, an office manager, a medical assistant, and two patients all from EHC, and a faculty member from Washington County Community College will join Gartmayer-DeYoung and Brown at the meeting in Augusta. 

Representing WCCC will be Nickey Dubey, who is an Instructor in Medical Assisting. “This is a first for the program,” Gartmayer-DeYoung said. “She is interested in taking the lessons learned and introducing it into her Medical Assistant training curriculum”. 

A nationally renowned expert on the topic, Bev Johnson, will give the keynote address. “She is going to talk about being patient centered and engaging the patient population, which is one of the themes of this learning session and the second part of it is going to be around behavioral-health integration,” Jennifer Hubbard, Quality Improvement Specialist for Maine Quality Counts, said. 

What is unique about this pilot project is that the scope of it reaches beyond Maine’s borders. 

“This is a national model,” Brown added. “It is being used to improve outcomes, reduce costs and increase access to care for patients. We are the only health center in Washington County that is participating in the Maine Patient Centered Medical Home Pilot Project.”

Now in the process of being implemented, Gartmayer-DeYoung said that the ultimate goal is for EHC patients to feel that they are in charge of their medical care. “Instead of being talked to, patients will find a shift to where they will be speaking with their provider and health care team,” she said.

Hubbard agreed. No longer will patients be told what to do, instead patients will take responsibility for their health care. “We want the patients to say, ‘What do I need to do to be healthy?’ And to recognize that they are a member of the care team,” Hubbard said.  “What they should start to see is that it should ultimately reduce costs, improve the care they are receiving in terms of quality time with their provider led care team and also find that there will be more encouragement around engaging them to be a participant in their own health care process.” 

But in the myriad medical world where chronic disease is a daily diagnosis for a medical provider, one might ask where to begin?

It will start with patients who have diabetes, Gartmayer-DeYoung said.  Dr. Laurie Churchill, EHC’s Medical Director, is in the process of creating a flow sheet to assist the health care team in managing the care needs of our diabetic patients. “Implementing this tool will result in standardizing care, educating staff, as well as educating patients on how to better care for themselves,” she added.

Brown said that although EHC was now focusing on diabetes, PCMH teams ultimately will focus on other health care issues. “We are going to begin our care focus with a very important condition because of the many health concerns that need to be considered when taking care of your diabetes. But over time we plan to make this overall health management, not just for chronic disease” Brown said. 

To make the program work, Gartmayer-DeYoung said that the health center welcomes anyone who would like to serve on either the Eastport or Machias Patient Advisory Councils. “Having the voice of our patients in this is critical to its success,” Brown added.

 Interested community members can contact Theresa Brown at tbrown@eastporthealth.org, or call 853-6001.

For more information about PCMH go to www.mainequaltycounts.org.