PCMH (Patient Centered Medical Home)

What Is a PCMH?

A Patient Centered Medical Home (PCMH) is a model of primary care that focuses on the patient’s entire well-being. As such, the PCMH includes a team of care providers (e.g. physicians, nurses, pharmacists, nutritionists, social workers and educators). As a PCMH we work closely with patients and their families, recognizing the unique needs, cultures and beliefs of each patient. With MHC Healthcare we coordinate care between specialty care, hospitals, home healthcare and community services. We provide many resources to care for our patients 24/7 with such resources as, urgent needs, around the clock telephone access to a provider and secure electronic message through our Patient Portal. MHC Healthcare, as a participant of a PCMH, is committed to quality care and quality improvement. Using methods of evidence-based medicine, clinical decision support tools, shared decision making with patients and families and engaging in performance measurement and improvement. In short, as part of a PCMH, MHC Healthcare is dedicated to providing the highest and most complete level of care for each patient.

Outcomes

In May of 2011, MHC Healthcare dedicated itself to receiving recognition from the National Committee for Quality Assurance (NCQA) as a Patient-Centered Medical Home (PCMH) for the Marana Main Health Center and its satellite locations. Between April and December of 2013, MHC Healthcare received Level III Recognition from NCQA under the 2011 PCMH standards for the Marana Main Health Center and ten satellites. MHC Healthcare is currently working to renew our recognition under NCQA’s 2014 PCMH standards.

This model of care is a team based health care delivery model led by a physician or nurse practitioner that provides comprehensive and continuous medical care to patients. Medical homes allow better access to health care, increase satisfaction with care, and improve care coordination activities.

MHC empowers patients to get involved in decision making and provide feedback to determine if their expectations are met. The Medical Home provides continuous overall care that integrates prevention, wellness and arranges care with qualified specialists and resources when needed to help patients make healthy lifestyle changes.

Dove Mountain Health Center & Urgent Care

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

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Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Clinica Del Alma Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

East Side Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Ellie Towne Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Freedom Park Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

 

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Flowing Wells Family Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Keeling Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Marana Main Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

MHC Primary Care Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Ortiz Community Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

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Santa Catalina Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.

Wilmot Family Health Center

The sharing of meaningful information helps the patient and medical practices make good decisions regarding patient care. In this section, MHC Healthcare is supplying quality measures regarding both Chronic Diseases and Preventive Care Measures.

Clinical Quality Performance

Influenza Vaccination

Percentage of patients (ages >6mo) that have received the annual influenza vaccination.

Pneumonia Vaccination

Percentage of patients (ages 18+) that have had a pneumococcal vaccination within the last 10 years.

Mammography

Percentage of female patients (ages 40-65) that have had a mammogram within the last 24 months.

Colorectal Cancer Screening

Percentage of patients (ages 50-75) that have been screened for colorectal cancer.

Controlled Diabetes

Percentage of diabetic patients with a most recent Hemoglobin A1c < 8%.

Managed Depression

Percentage of patients (ages 13+) that have depression and a current action plan.

Managed Pediatric Persistent Asthma

Percentage of patients (ages 5-18) with a diagnosis of persistent asthma and a current action plan, as well as a prescribed controller


Resource Use and Care Coordination

Closed Referrals

Percentage of referrals that have been closed out within the last 6 months.

Communication of Test Results

Percentage of "Always" responses to Patient Satisfaction Survey question inquiring about communication of test results.

High Risk Patients Seen Quarterly

Percentage of high risk patients that have been seen at least once quarterly over the last 12 months.

Discharged Patients 7-Day Follow-up

Percentage of hospitalized patients over the last 12 months that have had a follow-up appointment within 7 days of discharge.