Lake Huron Medical Center PHO Patient Centered Medical Home – Neighborhood

In addition to the Patient Centered Medical Home (PCMH), the Lake Huron Medical Center Physician Hospital Organization (LHMC PHO) is working on the concept known as the Patient Centered Medical Home-Neighborhood (PCMH-N). Much like the PCMH, the structure of the PCMH-N is focused on providing comprehensive and well-coordinated healthcare, while meeting the specific needs of each patient. In the PCMH-N, Primary Care Physicians (PCPs) and specialists will be involved in a team-like partnership. This collaboration will allow for the development of an Organized System of Care (OSC). By defining specific roles for PCPs and specialists regarding the treatment of a patient, the transfer and sharing of patient care information will enhance the management of patients.

An effective PCMH-N begins with informed patients. From there, relationships can develop between patient and physician, forming a strong primary care foundation. The next step is to have engaged specialists to complete a care team. With accountability, collaboration and care-coordination, the care team can develop specific care plans to effectively manage the health of the patient. Using evidence-based standards and aligned incentives, the physicians of Lake Huron Medical Center PHO will actively take part in the pledge of attaining higher health care standards, ultimately improving the health of the community it serves.

Interactions that take place between PCPs and specialists include pre-consultation exchanges, formal consultations, co-management, and the transfer of a patient to a specialist.

• The pre-consultation exchanges consist of the PCP communicating with the specialist to share patient issues, concerns, or obtain guidance from the specialist prior to the referral to the specialist. This pre-consultation can assist in determining the appropriate testing that might need to occur prior to a formal consultation or even whether a consultation is necessary.
• The formal consultation stage provides important patient diagnosis and possible treatment plans from the specialist to PCP.
• Co-management places the long term care of the patient into a shared responsibility between two or more physicians. While the specialist focuses on the referred medical and surgical condition, the PCP remains the first contact and contributes towards other aspects of care.
• The coordination between PCP and specialist for treating a patient provides mutual responsibility in the transfer of information that adds to the value of patient care. If a situation arises in which the PCP transfers a patient to a specialist, the patient will then be under the entirety of their health care relationship.

Clinical integration between PCPs and specialists is an essential goal moving forward for Lake Huron Medical Center PHO. Placing the responsibility of patient care on patients, PCPs, and specialists will require dedication towards the concepts of the PCMH and PCMH-N, ultimately shaping the best individualized care plan to meet the needs for each patient. The commitment of the LHMC PHO to team-based health management and the PCMH-N will result in healthier patients associated with Mercy PHO physicians.

For additional information on the PCMH-N and Lake Huron Medical Center PHO’s Team, feel free to contact us at 810-987-1046