Patient-Centered Medical Home

At Pinnacle Physicians Group, we are proud to serve our patients as a Patient-Centered Medical Home.

What is a Patient-Centered Medical Home?

A Patient-Centered Medical Home is an innovative comment team-based approach to providing healthcare services. The partnership develops from the patient, his or her primary clinician, and a healthcare team. Working together guided by evidence-based guidelines for medical care, the team will work to provide the best Healthcare Services possible for you.

What are the changes and additional benefits that I can expect?

Team-based care | One of our clinicians will serve and remain as your primary care clinician. However, we will have a team of Medical Assistants and support staff to work with you to meet all of your healthcare needs. New information systems tools will assist us (along with other resources), to provide personal medical care that is optimal for you.

Improved health access and communication | For urgent care issues during working hours, your primary care clinician (or another one of our team members), will evaluate you on the day you have an urgent health care need. You will simply need to call the main office number during working hours to schedule a same-day appointment with us. Many urgent health-care needs can be handled by your medical home team, thus avoiding a prolonged and expensive visit to the emergency department. If the office is closed, we will provide you with instructions on how to contact the Clinician on-call for further assistance. Additionally, you can communicate with the on-call Clinician via a Direct Message through our Web Portal.

Web-based system | Our offices have implemented a web-based computer system (Health Fusion), that will allow you to learn about a particular medical condition, electronically communicate with your healthcare team, and receive electronic reminders about your personal conditions, as well as reminders for appointments as well as health maintenance needs. You will find an extensive library of information regarding your health conditions as well as self-management documents (both in-office and on our web portal) for conditions such as Diabetes, Hyperlipidemia, and Obesity. We will be providing you with more information on how to enroll in such a system during your visit to our office.

As your primary care provider, I will:

• Learn about you, your family, life situations, and health goals and preferences. I will remember these as well as your health history every time you seek care and suggest treatments that make sense for you.
• Take care of any short-term illness, long-term chronic disease, and your all-around well being.
• Keep you up-to-date on all of your vaccines and preventive screening testing.
• Connect you with other members of your care team (specialists, health coaches, etc) and coordinate your care with them, as your health needs change.
• Be available to you after hours for your urgent needs.
• Notify you of test results in a timely manner.
• Communicate clearly with you so that you understand your condition(s)., and all of your treatment options.
• Listen to your questions and feelings, and to understand whether you feel emotionally overwhelmed by any medical condition impacting your health.
• I will respond promptly to you- and your calls- in a way that you understand.
• Help you to make the best decisions for your care.
• Give you information about classes, support groups, or other services that can help you learn more about your condition and stay healthy.

We trust you, as our patient, to:

• Know that you are a full partner with us in your care.
• Come to each visit with any updates on medications, dietary supplements, or remedies you’re using, and questions you may have.
• Let us know when you see other health care providers so we can help coordinate the best care you.
• Keep scheduled appointments or call to reschedule or cancel as early as possible.
• Understand your health condition: ask questions about your care and tell us when you don’t understand something.
• Learn about your condition(s) and what you can do to stay as healthy as possible.
• Follow the plan that we have agreed is best for your health.
• Take medications as prescribed.
• Use our patient portal to track your health and to share you personal health record when appropriate with other caregivers.
• Call if you do not receive your test results within two weeks.
• Contact us after hours only if your issue cannot wait until the workday.
• If possible, contact us before going to the emergency room so someone who knows your medical history can call for you.
• Agree that all health care providers in my care team will receive all information related to your health care.
• Learn about your health insurance coverage and contact your insurance provider if you have any questions about your benefits.
• Pay your share of any fees.