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Patient-Centered Medical Home

Patient-Centered Medical Homes are driving some of the most important reforms in healthcare delivery today. A growing body of scientific evidence shows that PCMHs are saving money by reducing hospital and emergency department visits, mitigating health disparities, and improving patient outcomes. The evidence we present outlines how the medical home inspires quality in care, cultivates more engaging patient relationships, and captures savings through expanded access and delivery options that align patient preferences with payer and provider capabilities.
 
Ghous A Yasin, MD
&
PATIENT-CENTERED MEDICAL HOME
 
Dr. Yasin’s Office is working towards getting certified as a Patient-Centered Medical Home Practice for our patients.
 
What is a Patient-Centered Medical Home?
~It is a team approach to providing total health care at our office for you. Your Medical Team consists of Dr. Yasin and his staff. 
 
Who is part of you Patient-Centered Medical Home Team?
~Your health care provider
~All other staff at your health care provider’s office
~Most importantly – YOU!  You are the most important person on your health care team.  Patient-centered is a way of saying that you are the focus of your health care.
 
What do you need to do as part of your Patient-Centered Medical Home team?
  1. < >Keep your medical home providers informed!< >Take an active role in your own health~Follow the health care plan that you and your team agreed on
    ~Set goals that you can reach.  Once these goals have been reached discuss new goals
    ~Tell you team if you are having trouble staying with your care plan or it is not working for you.
     
    What can you Patient-Centered Medical home do for you?
    ~Help you manage your health care -- taking into consideration the WHOLE package, including but not limited to:  medical, physical social and behavioral health needs
                            ~Help answer all your health questions
                            ~Listen to your concerns
    ~Coordinate your care if additional services are needed, including setting up care with medical specialists, behavioral health specialists and at other facilities  
    ~Provide you with tools such as educational material or other literature to assist in your self-management of your or your family member’s health using evidence-based guidelines – please see our website for more information
    ~Encourage you to play an active role in your own health
    ~Assist you with HealthCare Coverage – please see our website for more information
    ~Please reach Stephanie at (716) 260-1159 for any medical record needs in either transferring or receiving records
     
    wnypcm@hotmail.com
     
    Here is what we have been up to, taking better care of YOU!!
     
Ghous Yasin, MD runs frequent reports in an effort to ensure quality care. These reports are meant to capture our patient populations 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 reminders to you our patients. We have included some of our outcomes. Please take a moment to review our results. We hope this information explains why you may have experienced an increase in phones, letters or reminders from this practice.

Colonoscopy Reminders
Patients received outreach reminders from this office requesting they complete this screening.  We started out the year with 24% of the patients having completed the screening test, but by the end of 2016 we had 62% of patients having completed the screening test. The practice saw improvement in the completion rate in this area by 38%. 

Mammogram Reminders
Patients received outreach reminders from this office requesting they complete this screening.  We started out the year with 37% of the patients having completed the screening test, but by the end of 2016 we had 45% of patients having completed the screening test. The practice saw improvement in the completion rate in this area by 8%. 

Chronic Care Reminders

Congestive Heart Failure - Patients received outreach reminders from this office requesting they have an office visit with weight check, blood pressure check as deemed necessary by our providers in the management their CHF.  We started out the 2016 year with 77% of the patients having completed the blood pressure check, but by the 4th quarter of 2016 we had 74% of patients having completed the required office visit and screenings.  The practice did not see improvement in the completion rate in this area; we are still working on improving our compliance numbers.

 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 54% of the patients having completed the screening test, but by the 4th quarter of 2016 we had only 13% of patients having completed the required lab work. The practice did not see improvement in the completion rate in this area; we are still working on improving our compliance numbers.

Hypertension - Patients received outreach reminders from this office requesting they  have an office visit with blood pressure check as deemed necessary by our providers in the management their Hypertension.  We started out the 2016 year with 92% of the patients having completed the blood pressure check, but by the 3rd quarter of 2016 we had 91% of patients having completed the required office visit and bp check. The practice did not see improvement in the completion rate in this area; we are still working on improving our compliance numbers.

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 62% of the patients having received the needed immunization to protect them against.   We finished out the year with 33% 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 1%. 

Shingles Vaccination Reminders
Patients received outreach reminders from this office requesting they get immunized for Tetanus.  We started out the year 2016 with 4% of the patients having received the needed immunization to protect them against.   We finished out the year with 4% of the patients having received the needed immunization to protect them.  The practice did not see improvement in the completion rate in this area; we are still working on improving our compliance numbers.

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 year 2016 with 55% 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 79%.  The practice saw improvement in the completion rate in this area by 24%. 


 
       

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