PinnacleHealth Expands Patient-Centered Medical Home Model

PinnacleHealth is expanding its patient-centered medical home (PCMH) program to triple the existing program at FamilyCare sites throughout Central Pennsylvania.  First introduced in 2010 at the Lower Paxton and Marysville FamilyCare offices, the program supports patients as part of the Governor’s Chronic Care Initiative within the PA Department of Health’s Chronic Care and Welfare program. The Community Health Team grew to four nurses in four FamilyCare practices assisting providers to improve the lives of nearly 3,000 patients with chronic illness in 2011.
A medical home is a doctor's office or clinic where a team of healthcare professionals work together to provide a new model of expanded care to patients.  The team manages care for patients with any chronic illness, such as diabetes, congestive heart failure, hypertension, COPD or asthma and any other high risk condition. In addition, those who are discharged from a PinnacleHealth hospital or emergency room are followed closely.
“We are working with the sickest patients to improve their outcomes and quality of life,” explains Community Health Team Nurse Manager Becky Zook. “We review everything with them including home and social environment, medications, self management/disease support and blockers to success, to help them become independent in the management of their condition.”
Using the PCMH methods of care, the 30-day re-admission rate to the hospital remains zero percent for those who are part of our model. Those who do not participate or receive care elsewhere have 10-20 percent 30-day re-admission rate.

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