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Coordinating Your Care Through a Medical Home

If you have a chronic condition like diabetes or heart disease, staying healthy requires that you play an active—and sometimes unfamiliar—role in your care.

For example, you may need to take new medicines, change your diet and lifestyle, and check your blood sugar or blood pressure levels. Most likely, you will need to see your doctor and other health professionals, like nurses, pharmacists and other clinicians, more often than you did before.

Managing all of this can be a challenge. You’ll need to make changes in your daily routine and get used to new medicines. And you’ll want to keep track of the advice of your care team. This may require more appointments, more tests or more follow-up.

It’s no wonder that you may feel overwhelmed by it all.

There is a better way, however. It’s called a medical home or patient-centered care. The idea isn’t new, but it’s getting tested in new and larger ways. It takes a team approach to primary care—and puts the patient at the center of that team.

Medical home teams often work in a primary care doctor’s office or clinic. Team members can include doctors, nurses, pharmacists and physical therapists. They help coordinate the care of their patients—of any age—across a range of settings, such as health clinics, care by cardiologists or other medical specialists, and hospitals.

How is the medical home model different from regular medical care?

Medical home teams try to broaden your access to primary care, which can reduce the risk that a medical problem will get worse and require a hospital visit.

A medical home team also can help coordinate the care that you need beyond primary care. For example, if you have heart disease, you might need to be seen by a heart specialist. The medical home team can arrange for that visit, make sure you’re prepared, and make sure that any test results from the appointment are provided to the patient and communicated to the care team.

Some of the largest primary care groups in the United States have agreed on key principles of a patient-centered medical home. The groups include the American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association.

And, starting this summer, the federal government will launch a demonstration of the medical home model for Medicare patients. The three-year project will test this model on the care of older patients with certain illnesses that need ongoing medical monitoring, advising or treatment.

Medical home teams that want to take part in this project must be able to track patients’ test results, review medicines and follow up with providers. Doctors who use this model and have electronic medical records are encouraged to participate.

The results of the Medicare project will be important, as our population gets older and needs more health care. Today, people 85 and older are the fastest growing segment of the U.S. population, according to the U.S. Census. The 65 and older group is expected to double in size in the next 25 years.

Can you find a medical home in your community? The concept isn’t widespread, but it’s getting more popular. If your doctor or your family’s doctor is a member of one of the national primary care or pediatric groups, he or she may be familiar with medical homes.

If not, there still are things you can do to play an active role in your health. Talk to your doctor about this concept. Ask your doctor how he or she can work with you to coordinate your care and keep you informed. Being an involved, engaged patient can go a long way toward getting the care you need.

I’m Dr. Carolyn Clancy, and that’s my advice on how to navigate the health care system.

Carolyn M. Clancy, a general internist and researcher, is an expert in engaging consumers in their health care. She is the director of the U.S. Agency for Healthcare Research and Quality.

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