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Patient Centered Medical Home

At Our Family Doctor, our mission is to provide exceptional healthcare and a superior patient experience. We have been recognized as a Patient Centered Medical Home (PCMH) since 2012, which will further enhance our commitment to patient care. The vision of our physicians and the entire care team is to provide value to our patients by delivering individualized and exceptional care, in a cost effective manner with the implementation of technology to develop a new approach on health care.

Our Family Doctor partners with our patients and health care resources, to coordinate care and improve overall outcomes. We are proud to share that we continue to be committed to the ideals of the Patient Centered Medical Home including our commitment to the practice of evidence-based and/or evidence-informed medicine. Part of that commitment includes providing resources for our patients to help improve self-care. Included here are several resources that our patients might find useful. Our Family Doctor is also a Mission Health Partners Accountable Care Organization member of North Carolina. MHP providers work together to improve communication, utilize resources, ensure consistent care, and to satisfy patients with a great OFD experience.

TEAM BASED CARE: Within the PCMH, each member of the care team has their own unique role to play and works together with other team members to deliver patient centered preventive services, chronic disease management and complex care coordination. The team forms a working culture where the physician, medical assistant and other staff members collaborate so that all members of the team are functioning at the top of their licensure and skill sets.

PATIENT REGISTRY: The PCMH will maintain various lists of patients with particular conditions so that evidence-based parameters can be used to guide care and insure that the patients are receiving all that is necessary to reach their care management goals.

EVIDENCE-BASED CARE AND PROTOCOLS: The PCMH will use care management guidelines and protocols for preventive services and chronic disease care that are based on clear medical evidence and are available to all members of the clinical team.

PATIENT ENGAGEMENT IN SELF-MANAGEMENT OF CHRONIC DISEASE CARE: The PCMH will develop a collaborative approach between patients and the care team using a shared agenda and clearly defined responsibilities that enhances the patient’s skills, education and self-efficacy in order to best manage their chronic disease.

COMPLEX CARE AND DISEASE MANAGEMENT OF “HIGH RISK” PATIENTS: The PCMH will identify “high risk” patients such as those requiring frequent office visits, recently hospitalized patients, readmitted patients, those taking many medications and those with special needs. With the use of a Care Team to handle complex case management, care coordination and transitions between levels of care, PCMH will deliver more comprehensive medical care.

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