The medical home is not a place, but instead a model of providing primary care. In a medical home, care is coordinated between preventative care, chronic care and acute needs. A medical home is accessible, compassionate, family centered, patient, comprehensive, appropriate, coordinated and continuous.
The advanced medical home encompasses all of the above, while also incorporating innovations in care team and practice operations which target those with high health risks to help achieve their health care goals.
IC4’s coached team-based structure embodies this approach. Physician champions facilitate the work of the nurse care coordinator within each practice, serve as an advocate for best practices and encourage participating clinicians and other team members to grow together in improving care. Staff semi-annual surveys measure wellness, teamwork and burden of care and are summarized to provide feedback regarding model development in each practice.
Within the framework of the medical home, IC4 practices ensure enhanced delivery of care through:
- Longitudinal and relational primary care team service delivery
- Regular chronic care management visits (2-4 times per year)
- Comprehensive visits for patients with complex needs in collaboration with the patient’s care coordinator
- Direct access to accurate up-to-date community and governmental resources for the comprehensive needs of their patients
- Delivery of safe transition of care when needed
- Shared decision making and clear communication between patients and caregivers and the health care team
- Proactive and long-range planning using an understanding of the impact of social determinants of health and future life course expectations.