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San Diego Geriatric Care Management Enables “Patient Centered Medical Homes”

There is a lot of buzz these days round “accountable care organizations” (ACO’s) and “patient centered medical homes” (PCMH’s). With health care reform fiats and finances rolling down through CMS to the rest of the health care world, changes are coming to health care delivery systems.

For those of us in private sector geriatric care management, these changes are not changes at all but familiar operating systems. Take “patient centered medical homes.” Out here in the home care trenches, this has been a robust model of care for some time.

San Diego geriatric care managers being the organic facilitators of “long term care” in home and community based settings, naturally incorporate the basic principles of the PCMH which are:

– Care is relationship based and centered around the patient.

– Care is led by a primary physician who works with a multidisciplinary health care and home care team.

– Care is delivered by a “collaborative process,” not simply a vertical hierarchy. Accountability is horizontal as well as vertical.

– Enhanced access and flexibility of care, including patient and family (as appropriate) in decision making.

– Health information is delivered to primary physician/medical team in real time via PHR’s/telemedicine.

– Increasing use of home-based technology as feedback system and decision support.

With the growing use of health information technology in home care, this PCMH model will become increasingly important in improving patient outcomes, decreasing costs and in the general transformation of home care as we know it.

Geriatric Care Management in San Diego is at the creative edge of developing patient and family empowered prototypes for the future of home care.

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