LEADERSHIP | to help shape healthcare delivery that meets families’ needs
and coordinated, personalized care
delivered among primary care providers
and support staff distinguish the Baylor
Scott & White primary care clinics as
patient-centered medical homes.
Patients help to
shape their care
In the PCMH model of care, patients
are at the center of decision-making
and goal-setting. People with chronic
diseases, for example, work with
providers to set goals that will improve
their health, but are also realistic. “We
can tell patients all day they need to
change diet and exercise, but if that’s
not important to them, there’s no
way they’re going to do it. So we need
to figure out what is important to
them and help them reach that goal as
much as we can,” says Leanne Clark,
RN, director of clinical quality at
Baylor Scott & White Austin/Round
Rock Region.
Sometimes a patient’s goal is to see
a grandchild graduate from high school
or get married. So, the medical team
breaks that down into small steps to
make sure patients have the longevity
and health to get there, she says.
“Patients really need to be able to selfmanage whatever chronic conditions
they have, and to buy in to doing
it. It’s a whole team working with
the physician around the patient to
coordinate their care,” Ms. Clark says.
Patient-centered medical homes
also help providers and patients
maximize their time together through
pre-visit planning. A staff member,
“Patients really need to be
able to self-manage whatever
chronic conditions they have,
and to buy in to doing it. It’s a
whole team working with the
physician around the patient
to coordinate their care.”
—Leanne Clark, RN
22
THE CATALYST September 15 | sw.org
usually a medical assistant, looks ahead
to upcoming appointments and calls
the patient to come in for any blood
tests or X-rays that might be needed.
“If I as a patient need some labs, I
can come in ahead of my appointment
to get those tests done. That way my
doctor and I would both be prepared for
a good discussion at the appointment,”
says Dr. Hochhalter.
Technology delivers
more patient benefits
Primary care doctors (and specialists)
can now clearly see the goals a patient
has set right inside the patient’s
electronic medical record (EMR).
Although specialists and primary care
doctors have long been able to read
each other’s notes and test results, this
change lets doctors also see the patient’s
self-specified goals.
The EMR system and the online
patient portal called MyChart are
vital to the patient-centered medical
home effort. These are examples
of technology innovation that help
keep track of patients’ histories, issue
reminders for lab and other tests due,
and give patients an easier, more
convenient option to manage their care
and appointments, and communicate
with their doctors. These capabilities
help people when they are ill, and
during times of wellness when proactive
outreach is still needed to monitor or
maintain care ef