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December 10, 2014/Diabetes & Endocrinology

Patient-Centered Medical Homes: A New Model of Care for People with Chronic Conditions

PCMHs empower nurses and patients and streamline care


Cleveland Clinic’s new patient-centered medical homes (PCMHs) are empowering patients and nurses, streamlining appointments and improving outcomes. A nurse at Cleveland Clinic’s main campus explains.


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One of Carolyn Wright’s patients is a woman in her late 50s with diabetes. “She has been in and out of the hospital on separate occasions for different things,” says Wright, BSN, RN, who works in internal medicine at Cleveland Clinic’s main campus. But lately the revolving readmissions have tapered off, thanks in part to a team-based approach to care initiated and piloted by Cleveland Clinic’s Medicine Institute starting in 2012.

Three of Cleveland Clinic’s primary care locations, including the internal medicine department at main campus, adopted a patient-centered medical home (PCMH) model of care. Patients have a direct relationship with a primary care physician who works in tandem with a cooperative team of healthcare professionals to provide preventive care. Teams include registered nurses and medical assistants as well as other embedded resources, such as pharmacists, diabetes educators, physical therapists and social workers.

“Multiple healthcare providers surround patients and manage their care, providing all medical services needed,” says Jennifer D. Coleman, MSM, BSN, BSBA, RN, Clinical Nurse Manager of internal medicine and geriatrics. This team-based approach benefits patients tremendously. The diabetic woman regularly visits a pharmacist, who helps manage her insulin regimen. She calls Wright with questions, rather than heading to the emergency department, as she did in the past. If necessary, the nurse schedules a same-day appointment with the doctor or physician’s assistant.

“My patient has dramatically changed her willingness and motivation to care for herself,” says Wright. “She relies on our team to better manage her diabetes and has improved her HbA1c values.”

Providing collaborative care

Ingrid Muir calls patient-centered medical homes “the wave of the future.” Muir, MBA, BSN, RN, NE-BC, is Nursing Director of Cleveland Clinic’s Endocrinology & Metabolism and Medicine institutes. “It’s about developing trust with patients and coaching them,” says Muir. “You can only do that over time; not with episodic care.”

Care in the Cleveland Clinic PCMH begins with a report generated by the hospital’s electronic medical record (EMR) system. It flags patients who have recently been hospitalized with pneumonia or myocardial infarction and those with chronic conditions, such as diabetes, kidney disease and chronic obstructive pulmonary disease.

Medical assistants mail letters to identified patients, noting any lab tests or screenings that are needed prior to an appointment. During office visits, physicians and nurse care coordinators are paired and supported by the medical assistants who work together to determine if they need additional resources such as pharmacists or social workers. Patients are matched with care teams, so they see the same group of healthcare professionals.

“Working with one physician facilitates communication and strengthens collaboration,” says Lindsey Carlisle, RN, a care coordinator in internal medicine. “Nurses focus on a group of patients, rather than caring for patients of all doctors within a team.” Focused relationships lead to more efficient care, she adds.


After office visits and hospitalizations, care coordinators also make regular follow-up calls to patients. They ask about pain levels and concerns, and review medications and the plan of care. The overall goal is to provide continuity of care and empower patients to be active participants in the healthcare process. “We’re trying to stop people from falling through the cracks,” says Coleman.

Practicing at “top of license”

The PCMH model streamlines medical appointments and allows professionals to practice at the top of their licenses. As an example, medical assistants bring patients to examination rooms and obtain vital signs, complete medication reconciliation and prepare the patient for the appointment. Then, nurse care coordinators consult with patients and have time to dig deeper into the current problems and other psychological, social and economic factors that can affect a patient’s health status.

“I make sure they are up to date with immunizations and other health maintenance, but most important, I see if there are other concerns that might affect their health,” says Wright. “Many patients withhold or provide incomplete information when discussing their current problem. Sometimes, patients are unsure if symptoms are related to the current problem and fail to raise them as issues. I try to focus on the patient as a whole person.”

Patient centered medical homes “provide the structure to facilitate ambulatory nurses to practice at their peak,” says Muir. “Care coordinators are very seasoned nurses with a lot of knowledge. Tapping their expertise and experience will be game changing.”

Ultimately, Cleveland Clinic hopes the PCMH model improves patient outcomes. And all indications suggest that it has. “There’s been a decline in readmission in the three PCMH sites compared to their peers,” says Craig Martin, MPA, Quality Director of the Medicine Institute. “So we are hopeful that it’s having an impact.”

In the fall of 2013, Cleveland Clinic received the Joint Commission Primary Care Medical Home certification. In 2014, the PCMH model rolled out to more than 42 practices across the Cleveland Clinic health system. Nurses who piloted the model believe it is worthwhile. Carlisle states, “It allows me to impact chronic disease management in a comprehensive and innovative way.”


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