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Patient Centered Medical Home

PATIENT-CENTERED MEDICAL HOME

Suresh Sofat, MD. has been awarded recognition in the past and is currently working on re-recognition by the National Committee for Quality Assurance for Physician Practice Connections-Patient Centered Medical Home (PCMH)

NCQA is a private, non-profit organization dedicated to improving health care quality. Their recognition programs are built on evidence-based nationally recognized clinical standards of care.

What is a patient-centered medical home?

A patient-centered medical home is a system of care in which a team of health professionals work together to provide all of your health care needs. We use technology such as electronic medical records to communicate and coordinate your care and provide the best possible outcomes for you.
You, the patient, are the most important part of a patient-centered medical home. When you take an active role in your health and work closely with use, you can be sure that you’re getting the care you need.

Who is on the patient-centered medical home care team?

Your primary care provider leads your care team which may include specialized doctor, nurses, health educators, and other health care professionals such as pharmacists or physical therapists. Our team acts as “coaches” who help you get healthy, stay healthy, and get the care and services that are right for you. You, of course, are at the center of your care team.

How does a patient-centered medical home benefit me?

In a patient-centered medical home, we:

  • Are available when you need us. You can communicate with us easily and efficiently and get appointments quickly.
  • Know you and your health history. We know about your personal or family situation and can suggest treatment options that make sense for you.
  • Help you understand your condition(s) and how to take care of yourself. We explain your options and help you make decisions about your care.
  • Help you coordinate your health-care - even if we are not the ones giving you the care. We will help you find specialists, get appointments, and make sure specialists have the information they need to care for you.
  • Use technology such as electronic medical records and share records to help prevent medical errors and make sure that we are always on the same page.

HOW dO yOU gET tHE mOST fROM a pATIENT-CENTERED mEDICAL hOME?

What you can do:

1. Be in charge of your health

  • Know that you are a full partner in your care.
  • Understand your health situation and ask questions about your care,
  • Learn about your condition and what you can do to stay as healthy as possible.

2. Participate in your care

  • Follow the plan that you and we have agreed is best for your health.
  • Take medications as prescribed.
  • Keep scheduled appointments and attend follow-up visits when necessary.

3. Communicate with your care team, Keep your medical home providers informed!

  • Tell us when you don’t understand something we said or ask us to explain it in a different way.
  • Bring a list of questions and a list of medicines or herbal supplements you take to every appointment.
  • Tell us about any changes in your health or well being.
  • Let your health care provider know about care you receive from other health care professional
  • Call your medical home first with questions and appointment requests before your go to an Urgent Care Center or Emergency Room
  • Let your medical home know if you have been in the hospital. Call your provider as soon as you are discharged from the hospital to set up appropriate follow up visits.
  • Let your medical home know of any change in your medications after a hospital stay or from a visit with another health care professional
  • Bring all of your medication (or a list of your medication) with you to each visit

YOUR CARE TEAM WILL:

1. Get to know you

  • Learn about you, your family, your life situation, and preferences. We will update your records every time you seek care and suggest treatments that make sense for you.
  • Listen to your questions and feelings and treat you as a full partner in your care.

2. Communicate with you

  • Explain your health situation clearly and make sure you know all of your options for care.
  • Give you time to ask questions and answer them in a way you understand.
  • help you make the best decisions for your care

3. Support you

  • Help you set goals for your care and help you meet these goals every step of the way.
  • Give you information about classes, support groups, or other services that can help you learn more about your conditions and stay healthy
  • Send you to trusted experts when necessary


Suresh Sofat, MD wants to make sure you are familiar with your disease and encourages patient input in the decision-making process for treatment. There are a number of conditions we treat, here are some more common conditions. They are below, along with links that patients can access to learn more about their disease state and the process of care of that disease:

Diabetes

Coronary Artery Disease (Heart Disease)

ACOG: American Congress of Obstetricians and Gynecologists

AAA Abdominal Aortic Aneurysm

Diabetes

Attention Deficit Hyperactivity Disorder or ADHD

Cellulitis

Hypertension or High Blood Pressure

Treating Tobacco Use and Dependency

Keeping up to date on Well Child Physicals

Depressions Screening

Blood Pressure & Follow Up

Cholesterol

 

 

Population Management Outcomes

Patient Outreach

Suresh Sofat, MD runs frequent reports in an effort to ensure quality care. These reports are meant to capture the attention of members of our patient population who have not yet received various services, tests, screenings, vaccinations, etc. Our office staff places reminder calls, sends reminder letters, and utilizes the Patient Portal in an effort to provide quality care. We have included some of our outcomes on this website. Please take a moment to review our results. We hope this information explains why you may have experienced an increase in outreach attempts from this practice.

PSA Blood Test Reminders
Patients received outreach reminders from this office requesting they complete this screening.  We started out the year with 40% of the patients having completed the screening test, but by the end of 2016 we had 68% of patients having completed the screening test. The practice saw improvement in the completion rate in this area by 28%. 
Mammogram Reminders
Patients received outreach reminders from this office requesting they complete this screening.  We started out the year with 44% of the patients having completed the screening test, but by the end of 2016 we had 49% of patients having completed the screening test. The practice saw improvement in the completion rate in this area by 5%. 
Chronic Care Reminders
 Diabetes - Patients received outreach reminders from this office requesting they complete the lab work deemed necessary by our providers in the management of diabetes.  We started out the year with 66% of the patients having completed the screening test, but by the end of 2016 we had 65% of patients having completed the required lab work. The practice did not see improvement in this area but we will continue to strive to take better care of our patients through more regular testing. 
Chronic Obstructive Pulmonary Disease (COPD) patients needing a Spirometry(breathing test) - Patients received outreach reminders from this office requesting they complete the breathing test deemed necessary by our providers in the management of COPD.  We started out the 2016 year with 44% of the patients having completed the breathing test, but by the end of 2016 we had 69% of patients having completed the required breathing test. The practice saw improvement in the completion rate in this area by 29%. 
Hypertension and patients needing blood pressure checks - Patients received outreach reminders from this office requesting they complete regular office visits with blood pressure checks deemed necessary by our providers in the management of Hypertension.  We started out the 2016 year with 78% of the patients having completed the needed visit and bp check, but by the end of 2016 we had 87% of patients having completed the required breathing test. The practice saw improvement in the completion rate in this area by 9%
Pneumonia Prevention Vaccine Reminders 
Patients received outreach reminders from this office requesting they get immunized for pneumonia prevention.  We started out the year 2016 with 69% of the patients having received the needed immunization to protect them against.   We finished out the year with 75% of the patients having received the needed immunization to protect them against pneumonia. The practice saw improvement in the completion rate in this area by 6%. 
Zostavax Vaccination Reminders
Patients received outreach reminders from this office requesting they get immunized for Shingles.  We started out the year 2016 with 0% of the patients having received the needed immunization to protect them against.   We finished out the year with 19% of the patients having received the needed immunization to protect them. . The practice saw improvement in the completion rate in this area by 19%. 
Medication List Reconciliation
Patients who come in for an office visit have their medication list reviewed or reconciled during the visit.  We started out the 2nd quarter of 2016 with 63% of the patients having their medication list reviewed or reconciled during the visit.   By the 3rd quarter we had increased the percent of patients having their medication list reviewed or reconciled during the visit to 96%.  The practice saw improvement in the completion rate in this area by 33%. 
 

Patient Satisfaction Survey Results

 

 


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