The patient is at the center of Summit Medical Group’s Patient Centered Medical Home (PCMH) care delivery model. The Patient Centered Medial Home consists of a physician-led team which supports the delivery of the right health care services, at the right time, and in the right setting with the goal of obtaining maximized health outcomes.
For many of Summit’s Medicare patients, the Care Coordinator plays a key role in the Patient Centered Medical Home by assisting the patient and their family in the identification of care needs and the smooth delivery of services to address those needs. As a patient’s care needs become more complex, the number of services and service providers tends to increase. In situations like this, the Care Coordination staff can act as the facilitator for the patient, family, and the physician without any charge to the Medicare patient.
Summit’s Care Coordination team is made up of nursing and social worker professionals who work together with Summit’s Medicare patients and their physicians to arrange and coordinate care and services. Through Care Coordination, complex situations and resources needed to carry out patient care activities can be organized. The following list represents some of the activities routinely performed by the Care Coordinators as a service to our Medicare patients:
- Help Medicare patients and their families navigate the health care system so they have the best care possible.
- Perform individual assessments to better understand the patient’s needs.
- Provide assistance with things such as transportation or caregiver support.
- Help those with chronic illnesses such as Diabetes, Asthma, Heart Failure, and others learn to manage their illnesses better in order to achieve better health.
- Help identify programs that can help the patient cut down on the costs of needed services.
- Help patients set goals and solve problems for improved self-management.
- Under physician direction, apply evidence-based strategies to reduce complications, optimize disease control, and patient well-being.