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Chapter 4

Medical Home: Health Maintenance Success During the Visit, Part 1

Holly Tse, MD and Neda Frayha, MD

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What is a medical home and how can it help us succeed in keeping patients current on their screenings and chronic disease management? Dr. Holly Tse gives Neda super practical tips on how we can rock our health maintenance core measures in this two-part series.


  • A key mindset to the medical home is the idea of whittling away at health care maintenance by doing a little bit at every visit.

  • Invest the time and energy into building good relationships with your team and learn the EMR to help accomplish the task of caring for the patient before, during and after the visit.


  • What is the concept of a “medical home”?

    • Popularized in 2007

    • Instead of thinking of the PCP just seeing individual patients, the PCP is the leader of a multidisciplinary team and clinic focused on delivering care not just for every single patient but for the whole panel of patients

    • Team of different people with different skill sets that care and support the patient holistically

  • What is the primary goal of a medical home?

    • Improve the patient experience, population health and decrease the cost of care

    • Provide a framework for the clinic to function in so you have structures in place to be thinking about a population of patients and not just the one in front of you

    • Oftentimes, this also means committing to and closely tracking quality metrics that may get incentivized through payments from payers to help fund other staff time

  • Examples of core metrics:

    • Chronic disease management

    • Behavioral health

    • Preventative health (ie: cancer screenings, vaccinations)

    • Utilization measures (ie: ED usage, readmissions)

  • Practical tips for health maintenance before and during the visit:

    • Pre-charting (See April 2020 PCRAP for additional tips)

      • Look ahead at the chart to see what health maintenance may be due

      • Pend orders

      • Start a note, write a blurb about health care maintenance

    • Determine a workflow for the MA to be scrubbing the chart ahead of time

      • They may look at it before the visit and let you know what might be due at what time

    • Team huddle in the morning

      • Review patients and a plan of action for when they come like point-of-care testing, diabetic foot exam, smoking cessation reminders for the provider

    • Develop workflows with your team

      • Share the importance of health maintenance with your MA and co-develop workflows to get their input/buy-in

      • Share the benefits and show thanks for the work for the team (ie: bonus incentives, lunch, etc.)

    • Address health care maintenance at every visit:

      • Every visit can be an opportunity to chip away at preventative medicine tasks

        • Even things like a PHQ-2 that may be coming up due, address it in the visit even if it means it may lead to a PHQ-9. You can always schedule another visit to discuss the PHQ-9.

        • Labs that may be coming due may be best to address at the visit if you aren’t going to see the patient soon again

      • It also emphasized the importance to patients and gives them multiple opportunities to think about it

    • Be firm in your recommendations, show concern and signal you are listening:

      • “I care about you. It's important. It's my job to keep you healthy and prevent problems."

      • “I hear you.”

    • Conduct health care maintenance WITH the patient in the room:

      • Saves you time

      • Less chance you’ll forget

      • Demonstrates to the patient the time it takes you to do these things like sending a referral or placing an order

  • Wrapping up the visit:

    • Type the plan into the after-visit summary with the patient in plain language

      • Allows them to ask clarifying questions

      • Demonstrates the work of doing preventative medicine

    • Schedule the next visit at the current visit:

      • "Hey, as we're wrapping up, I always think about when we should see each other again. We handled a lot today and we made some decisions. So maybe we should meet again in a month. It could even be a video visit now that we've had this in-person visit."

    • Try to order the standard things BEFORE the next visit:

      • With data in hand at that visit, you can manage it during the visit instead of managing it afterward



  1. “Oregon Health Authority : Patient-Centered Primary Care Home Program : Patient-Centered Primary Care Home Program : State of Oregon.” Link

  2. American Academy of Family Physicians. Joint principles of the Patient-Centered Medical Home. Del Med J. 2008;80(1):21-22. PMID: 18284087

  3. Patient-Centered Medical Home (PCMH) - NCQA. NCQA. Published 2011. Link

  4. Defining the PCMH | PCMH Resource Center. Published 2019. Link

  5. Defining the Medical Home | Patient-Centered Primary Care Collaborative. Published 2017. Link

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