Women's Medicine Collaborative primary care team earns NCQA recognition

The Women's Medicine Collaborative primary care team has been designated a Level 3 Patient-Centered Medical Home (PCMH) by the National Committee for Quality Assurance (NCQA). The patient-centered medical home model of care emphasizes using coordination and communication to transform primary care to accommodate patients' needs. Having a nurse care manager work one on one with high-risk patients who have chronic conditions leads to a higher quality, better patient experience and reduced costs. Level 3 is NCQA's highest designation in its recognition program.

"Since the Women's Medicine Collaborative opened its doors in 2011, our primary care team has been focused on achieving this important designation," says Peg Miller, M.D., director of the Women's Medicine Collaborative. "Our patients at the Women's Medicine Collaborative expect personal, sensitive, individualized care, something everyone on our team focuses on each and every day. This designation recognizes those efforts and showcases our group as a model for delivering health with care."

Facets of patient-centered medical homes include after-hours and online access, shared decision making and team-based care, patient engagement on health and health care, and lower costs related to reduced emergency department and hospital use. The PCMH care model encourages getting to know patients through long-term partnerships and making treatment decisions with patients based on individual preferences. Nurse care managers, for example, may work closely with patients struggling to manage the complexity of multiple medications and appointments, help to coordinate a plan of care, and provide patients with the tools needed to manage their condition and to reach health-related goals. This increases patient satisfaction and reduces hospital admissions and ED visits.

Ann Marie DeAngelis has been a patient at the Women's Medicine Collaborative since it opened four years ago. She works one on one with Women's Medicine Collaborative nurse care manager Kathy Congdon, RN, CDOE, through office visits, telephone, and the Women's Medicine Collaborative Patient Portal - obtaining answers to medical questions along with customized, measurable short-term action plans for improved health.

"The Women's Medicine Collaborative addresses the need of someone to 'fill in the gap' for people with a lot on their plate who need help managing their medical issues and suggested treatment plan," says DeAngelis. "This resource of nurse care manager was created to help us who need it - to have someone ask the right questions and explain things in a way that patients can understand. I recommend trying this resource if you are overwhelmed with your medical issues, have a new or scary diagnosis, need some guidance, or just need help to put it all together and make a plan."

The PCMH team also empowers patients to become more engaged and active in their own health care. The team approach maximizes efficiency by enabling coordination of care from other providers and community resources, and costly and preventable complications and emergencies are avoided by focusing on prevention and management of chronic conditions.

DeAngelis says, "I feel that I am in better control of my life. I am improving medically because I'm doing my part, while being monitored, directed, and encouraged by the Women's Medicine Collaborative medical team. Their team approach and Kathy's role of viewing the patient as a full package with complete awareness of related emotional and psychological effects is refreshing."

To earn NCQA recognition, practices must meet rigorous standards for addressing patient needs, including:

• Patient-centered access: accommodating patients' needs during and after hours, providing medical home information, and offering team-based care

• Team-based care - engaging all practice team members by providing patients comprehensive care and meeting cultural and linguistic patient needs

• Population health management - collecting and using data to help improve the care of our group of patients

• Care management and support - using evidence-based guidelines for preventive, acute care, and chronic care management and helping patients reach their health goals with the support of our nurse care manager

• Care coordination and care transitions - tracking and coordinating tests, referrals, and care transitions

• Performance measurement and quality improvement - tracking and using medical data for continuous improvement in the quality of our care

"The medical home model aims to meet patients' individual health needs by providing comprehensive, coordinated and accessible care that is focused on quality and safety," says Iris Tong, M.D., FACP, director of Women's Primary Care at the Women's Medicine Collaborative. "This team-based care model involves patients, primary care providers, medical assistants, patient service representatives and the nurse care manager, and as part of the Women's Medicine Collaborative, Women's Primary Care takes a team approach to all the care we provide - from assisting in coordinating appointments with specialists to guiding patients through the health care system."

"In today's world, it's refreshing to be part of a medical organization that looks at the patient as a full package and truly cares about all aspects of the person," DeAngelis says. "I believe that the Women's Medicine Collaborative wants all of its patients to be happy and healthy."

She adds, "I always leave my appointments feeling positive, successful, connected and encouraged. Everyone gets dealt a different hand. It's not what you get, but rather, how you deal with it."