PATIENT-CENTERED MEDICAL HOME
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.

Dr. Gregory Jehrio, MD & PATIENT-CENTERED MEDICAL HOME 

Gregory Jehrio, MD is currently recognized level 3 by the National Committee for Quality Assurance for Patient Centered Medical Home (PCMH). NCQA is a private, non-profit organization dedicated to improving health care quality. Their recognition programs are built on evidence-based nationally recognized clinical standards of care.

What is a Patient-Centered Medical Home?

A patient-centered medical home is a system of care in which a team of health professionals’ work together to provide all of your health care needs. We use technology such as electronic medical records to communicate and coordinate your care and provide the best possible outcomes for you.

You, the patient, are the most important part of a patient-centered medical home. When you take an active role in your health and work closely with use, you can be sure that you’re getting the care you need.
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?

• Keep your medical home providers informed!
• Let your health care provider know about care you receive from other health care professionals outside of our practice
• Please work with your health care provider to provide your complete medical history
• Call your medical home first with any questions about your health and appointment requests before you go to an Urgent Care Center or Emergency Room!
• Call our office at (716) 439-0202 during regular business hours
• After Hours and on Weekends call (716) 439-0202 for our answering service
• Let your medical home know if you have been in the hospital. Call your provider as soon as you are discharged from the hospital to set up appropriate follow up visits.
• Let your medical home know of any change in your medications after a hospital stay or from a visit with another health care professional
• Bring all of your medication (or a list of your medications) with you to each visit
• 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 the office staff at (716) 439-0202 for any medical record needs in either transferring or receiving records

Population Management Outcomes
Here is what we have been up to, taking better care of YOU!!

Gregory Jehrio, 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.
Colorectal Screening Reminders
Patients received outreach reminders from this office requesting they complete this screening. We ended the 4th quarter of 2016 with 50% of the patients having completed the screening test, but by the end of the 2nd quarter of 2017 we had 51% of patients having completed the screening test. The practice saw improvement in the completion rate in this area by 1%. 

 Mammogram Reminders
Patients received outreach reminders from this office requesting they complete this screening. We ended the 4th quarter of 2016 with 26% of the patients having completed the screening test, but by the end of the 2nd quarter of 2017 we had 42% of patients having completed the screening test. The practice saw improvement in the completion rate in this area by 16%. 

Chronic Care Reminders 
Chronic Obstructive Pulmonary Disease (COPD) patients needing a Spirometry(breathing test) - Patients received outreach reminders from this office requesting they complete the breathing test deemed necessary by our providers in the management of COPD. We ended the 4th quarter of 2016 with 0% of the patients having completed the required breathing test, but by the end of the 2nd quarter of 2017 we had 0.8% of patients having completed the required breathing test. 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 ended the 4th quarter of 2016 with 38% of the patients having completed the screening test, but by the end of the 2nd quarter of 2017 we had 47% of patients having completed the required lab work. The practice saw improvement in the completion rate in this area by 9%. 
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 ended the 4th quarter of 2016 with 100% of the patients having completed the screening test, but by the end of the 2nd quarter of 2017 we had 100% of patients having completed the screening test. The practice did not see improvement in the completion rate in this area because we are already doing so well, we will continue our efforts to maintain this high percentage

Pneumonia Prevention Vaccine Reminders  
Patients received outreach reminders from this office requesting they get immunized for pneumonia prevention. We ended the 4th quarter of 2016 with 12% of the patients having received the needed immunization to protect them, but by the end of the 2nd quarter of 2017 we had 12% of 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.

Tetanus Vaccination Reminders
Patients received outreach reminders from this office requesting they get immunized for Tetanus. We ended the 4th quarter of 2016 with 4% of the patients having received the needed immunization to protect them, but by the end of the 2nd quarter of 2017 we had 5% of patients having received the needed immunization to protect them. The practice saw improvement in the completion rate in this area by 1%. 

Medication List Reconciliation
Patients who come in for an office visit have their medication list reviewed or reconciled during the visit. For all of 2016 we had 49% of the patients having their medication list reviewed or reconciled during the visit. By the 1st quarter of 2017 we had increased the percent of patients having their medication list reviewed or reconciled during the visit to 96%. The practice saw improvement in the completion rate in this area by 47%. 

Attention Deficit Hyperactivity Disorder or ADHD:

Treating Tobacco Use and Dependency:

AAA Abdominal Aortic Aneurysm:

Hypertension or High Blood Pressure:

Dr. Jehrio would like to provide you with tools to self-manage and monitor your health. Please find the following online tools and below downloadable documents to help you reach your health goals we talked about at your last visit. 
ONLINE PATIENT SELF-MANAGEMENT RESOURCES

African American Health
National Heart, Lung and Blood Institute
www.nhlbi.nih.gov/health/educational/healthdisp/health-education-materials/african-american.htm

Choose My Plate
US Department of Agriculture
www.choosemyplate.gov

Common Health Conditions Affecting Women
(Over 40 free fact sheets in English, Spanish, and other languages)
US Food and Drug Administration (USDA)

Diabetes in Asian and Pacific Islander Americans
National Diabetes Clearinghouse

Diabetes Portion Quiz
National Heart, Lung and Blood Institute

National Diabetes Information Clearinghouse
National Institute of Diabetes & Digestive & Kidney Diseases

National Quality Measures Clearinghouse
Agency for Healthcare Research and Quality

Women’s Health Publications
FDA Office of Women’s Health (OWH)

Patient Education/Self-Management Classes
Dr. Jehrio would like to provide the following documents to you to assist your discussions with your families and health care providers regarding your wishes if you are ever unable to speak for yourself.
New York State Health Care Proxy York State Health Care Proxy
Medical Orders for Life Sustaining Treatment (MOLST)
Patient Satisfaction Survey Results
This is how you said we did!

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