PHC-Troutman Family Medicine Working Toward Patient-Centered Medical Home Recognition

PHC-Troutman Family Medicine is working toward Patient-Centered Medical Home Recognition. The National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) Recognition is the most widely used way to transform primary care practices into medical homes.

According to the NCQA, a PCMH inspires quality in care, cultivates more engaging patient relationships, and captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities.

Located in Troutman, North Carolina, Troutman Family Medicine offers complete primary care services for all ages. As a part of the PCMH transformation process, Amrish Patel, MD, and the entire staff at PHC Troutman Family Medicine identified and implemented several quality improvement projects over the past several months including:

• Decreasing the number of diabetic patients with an A1C greater than 9 – improved scores by 23% from quarter 3 to quarter 4.
• Decreasing the number of patients who needed to come in for a skin cancer check appointment – improved scores by 36% from quarter 1 to quarter 4
• Decreasing the number of patients who need MenVeo and T-Dap immunizations – improved scores by 2% from quarter 1 to quarter 4.
• Decreasing the number of patients who are overdue for their Annual Wellness Visit – improved scores by 37%
• Decreasing the number of less than 30-day hospital readmissions from 14% in Quarter 3 to 9% in Quarter 4.
• Implementing a campaign to women who are overdue for their mammogram- improving scores by 12% from quarter 3 to quarter 4
• Decreasing the average time for a hospital discharge follow-up appointment from 9 days in quarter 1-3 to 8 days in quarter 4.
• Implementing a Care Coordination department staffed with nurses and a clinical team. Their role is to reach out to patients by phone in between their visits to the office, working with patients to help them meet their health goals (lowering blood pressure, lowering blood sugar, increasing exercise, weight loss, etc.).
• Additionally, PHC Troutman Family Medicine determined through a patient satisfaction survey that patients were not always able to get in for appointments at the time they would like. The practice improved its quality of care by opening up same day appointments, continuing to take walk-ins, and adding after-hour’s appointments two days a week.