The Patient Centered Medical Home

Coastal Medical is a Patient Centered Medical Home (PCMH) Group Practice:

A Patient Centered Medical Home (PCMH) is a primary care medical office that puts the patient in the center of their health care. The PCMH model of care creates care teams that help patients understand all of the services that they will receive today, or may need in the future - even if the services are not being provided in the primary care office. 

PCMH practices like Coastal Medical are collaborative. Providers work as a team with in-office Nurse Care Managers and Clinical Pharmacists, as well as hospitals and specialists such as; Cardiologists, Urologists, behavioral health professionals, nutritionists, etc., as needed, to ensure each patient gets the care they need at the right time.

Coastal Medical PCMH practices focus on preventive versus reactive care. This new model helps spot health concerns earlier and manages chronic conditions better than the older reactive model of care. At Coastal Medical, our heath care teams partner with patients and their families and make every effort to understand and respect each patient’s unique needs, culture, values, and preferences.

Our PCMH practice supports patients in learning to manage and help to organize their own care. We want you to be an active member of your care team. Recognizing that patients and families are core members of the care team, PMCH practices like Coastal Medical work with patients to provide proactive, comprehensive care, better access to care and more coordinated care for their patients.

Here are a few ways we do this for our patients:

• We offer weekend and holiday sick appointments so you do not have to visit the emergency room when you are sick. Always call your Coastal Medical primary care physician first!
• We have an online “Patient Portal” where you can update your personal information, view your health record, check appointment dates and view your lab results.
• We ask for your email so we can send you important information related to your health through the Patient Portal.
• The Electronic Medical Record (EMR). All of our offices use the same EMR. We have all of your important health information in “the record” which gives us the ability to track and proactively help patients with chronic health issues. The record also helps us coordinate your care with other providers involved with your healthcare.
• Our website is full of health information and ways to find a doctor, or contact the office where you are already a patient.

What can you do to help? Join the team!

• Talk with your team about your health questions. Prepare 3 questions for your team before your visits.  Share successes and challenges you have had with your care in the past.
• Tell your team about other healthcare providers caring for you
• Take care of your health by following the plan you and your team have designed for you.
• Set goals you can reach and sincerely work toward them.
• Talk openly with your team, if you are having trouble sticking to your care plan, let someone know.
• If you feel the plan is not working, speak up and ask for changes

Preventive Care:

Preventative care is care that focuses on disease prevention and health maintenance. It includes early diagnosis of disease, discovery and identification of people at risk of developing specific problems, provides counseling, and other necessary intervention to prevent a health problem before it becomes chronic. Screening tests, health education, and immunization programs are common examples of preventive care.

Reactive Care

In this old model of care, patients are not well monitored and are not part of a care team that is coordinating and looking after their health. The patient is alone in managing their care and often does not see the doctor until they are sick. This makes managing and preventing chronic health conditions much more difficult and the patient’s overall health suffers.

Quality Matters:

In order to be recognized as a PCMH practice, each of our medical offices must meet a set of quality standards in patient care – this means our providers are more accountable than ever for the care they provide. Coastal practices are NCQA Level 3 recognized – this is the highest level quality rating that can be achieved at this time. We are one of a small number of NCQA level 3 recognized practices in Rhode Island.

What is NCQA Recognition?

National Committee for Quality Assurance (NCQA) identifies and recognizes physicians who deliver superior care using standards firmly rooted in medical evidence. NCQA Annual Recognition highlights the commitment to provide quality health care to patients and demonstrates that we have incorporated quality improvements into our practices. Recognition is awarded after annual evaluation by NCQA on many aspects of our medical office practices and performance, including, Access and Communication; Patient Tracking and Registry Functions; Care Management; Patient Self‐Management Support; Electronic Prescribing; Test Tracking; Referral Tracking; Performance Reporting and Improvement; and Advanced Electronic Communications.

What is Comprehensive Care?

As a PCMH, Coastal practices are accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers. This team might include physicians, nurse care managers, physician assistants, clinical pharmacists, nutritionists, social workers, educators, care coordinators such as office staffs.  

What is Coordinated Care?

At Coastal, we manage our patients care across all parts of the health care system, including specialty care, hospitals, home health care, and community services and supports. This kind of coordination is particularly important during transitions between sites of care, such as when patients are being discharged from the hospital. Coastal practices provide Nurse Care Managers to patients transitioning from hospital to home. We have found that the support of the nurse care manager lowers the chance of readmission to the hospital. We work hard at building clear and open communication among patients and families, as well as the rest of the medical care team.

Better Access to Care:

PCMH practices like Coastal Medical offer shorter wait times for appointments, weekend and/or evening hours for appointments and around-the-clock telephone or electronic access to personal health information. Coastal Medical is working hard to provide improved access for our patients by offering same day in-office sick visits, same day laboratory and imaging services, weekend and holiday sick visit by appointments, better access to specialists, access to your health information through our Patient Portal and a wealth of health information and physician contact information on our website.

An Organized Approach to Quality and Safety:

Our PCMH practices demonstrate a commitment to quality improvement by regular participation in the use of evidence-based medicine and clinical decision-support tools to help patients and families make decisions about their healthcare. By taking part in performance measurement and improvement efforts, and measuring patient experiences and patient satisfaction, as well as practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

What is Evidence-based Medicine?

The careful and regular use of the best current medical evidence in making decisions about the care of each individual patient. Evidence-based medicine (EBM) is meant to integrate clinical expertise with the best available research evidence and patient values. EBM was initially proposed by Dr. David Sackett and colleagues at McMasters University in Ontario, Canada.

Why we need your email:

We routinely ask all patients to share their email with their physician’s office. We do this so we can contact you with health information we feel will be important to you. Coastal Medical will make every effort to contact you with only the most important health related information. We appreciate the trust you have placed in us by sharing your email and we assure you that we will not distribute your personal information without your express consent.

What is a care team?

A well-functioning PCMH is all about a team of people working together towards a common goal: delivering exceptional health care to patients. Every member of the team, including the patient, needs to know that that their efforts and ideas are valued. Coastal Medical care teams are led by your physician and include: nurse care managers, pharmacists, medical assistants and the entire office staff – everyone on the team is working for you!

Nurse Care Managers:

Here are a few important services a nurse care manager can provide to support better patient health:

• Review your care plan with you and share knowledge to help you better manage your health.
• Coordinate outreach to patients who might benefit from one-on-one health reviews.
• Work with you to help you navigate the healthcare system. Once you have developed the plan for your care with your physician, the nurse care manager can support you in following through with that plan.  The NCM can help connect you to resources in the community to achieve your goal of better health.
• Provide post hospital follow-up visits to patients that help them understand how to better care for themselves, or manage their medications, in an effort to prevent hospital readmissions.

Clinical Pharmacists:

Our clinical pharmacists will meet with you at your doctor's office, or over the phone, for a free medication consultation.  They see patients one-on-one for medication reviews, medication teaching, medication management, collaborative diabetes management, collaborative lipid management, collaborative hypertension management, and other chronic illness management.

Also, our clinical pharmacists can:

• Identify side effects of dangerous drug interactions between prescription and non-prescription drugs.
• Look for effective ways to lower the costs of your prescriptions.
• Provide a detailed medication schedule.

If you have questions about your medications, call your Coastal Medical office today.

The Electronic Medical Record and why is it important? 

An electronic medical record (EMR) is a digital version of the traditional paper-based medical record for an individual. An electronic health record (EHR) is an official health record for an individual that is shared among multiple facilities and agencies such as your physician, your specialist or the hospital where you have been treated. The EMR is very important because your physician can monitor whole groups of patients and, based on the information in “the record” can know what proactive steps to take to keep you healthy.

What is patient engagement, why is it important?

Patient engagement in action looks like shared responsibility between patients and their families, and the entire team of healthcare providers and healthcare staff. The goal of engagement is to work as a team to develop systems for the very best individual, community and population health. Patient engagement brought to life, means involving patients and caregivers in every step of their healthcare process, providing training or other supports if necessary to support their participation.

Engaged patients receive the greatest benefit from the health care services available to them because they are deeply involved in their own healthcare and use the information and professional advice from their care team to benefit their health and manage and cure disease.

Engagement is important because patients who are engaged have a better support and general understanding of their healthcare needs. Because they value and act on the education from their healthcare team, they have better overall health than patients who are not engaged.

What is the patient portal?

The Coastal Medical Patient Portal allows you to log into our secure system and manage your health care from any location with internet access.

On the patient portal you can:

• View Personal Information
• View Your Health Record
• Receive Educational Materials
• Receive Appointment Reminders
• Request Prescription Refills

Coming soon…

• View and pay billing statements online.

To sign up for the portal you will need a valid email address and one form of photo identification. Because you sign up for the portal in your physician's office, please speak with your health care provider at your next appointment, or stop in the office for more information.