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The Future of Patient-Centered Care

Medical Home keeps healthcare teams in-sync
When you’re sick, you go to the doctor when you’re able. You’ll get some good advice about your problem. Maybe a prescription. And then you’re on your way.

But what happens to care after you leave your provider’s office?

Your continued good health depends on how well you and your doctor communicate away from the medical office, not just when you’re there. 

“The medical home is really about more proactive, patient-centered care, determining their needs and finding the best way to meet those needs.”

--Thomas Graf, M.D., Chairman, Geisinger Community Practice Service Line

Geisinger is there

Creating a circle of care
It starts with Medical Home. A Medical Home isn’t a building. It’s an idea. It puts a patient’s primary doctor in charge of a team that includes a ProvenHealth Navigator (PHN) care manager, families, hospitals, specialists, pharmacists and skilled nursing facilities. The team works closely together to ensure the patient gets a high-level of preventive care to decrease the need for unnecessary hospitalizations.

The benefit? Questions get answered. Early warning signs are addressed. Emergency visits are avoided. Communication between health plans, patients and providers is stronger.

Removing barriers to care
ProvenHealth Navigator — along with Medical Home — removes the barriers between health plans and providers, putting chronically ill patients and their families at the center of customized healthcare. 

Whether the patient is healthy, recently ill or has a chronic condition, PHN can improve care coordination, reduces costs, enhances healthcare access and allows for more effective case management.

Where we’re headed
Geisinger Bloomsburg Hospital (G-BH) is building plans to offer G-BH Care Manager follow-up calls to patients across the payer groups who are discharged with chronic conditions, such as CHF, diabetes and COPD.

The goal
To reduce readmissions and ensure patients are following discharge plans and self-care at home, a G-BH Care Manager would make calls to discharged CHF, COPD and diabetes patients.

Care managers will work with Medical Home nurses to make contact with every patient within 48 hours after discharge. Patients will receive guidance on:

  • Weight management and proper diet
  • Blood sugar levels 
  • Keeping follow-up appointments

By working together with Medical Home nurses, payers and patients, we’ll help keep the community healthier at every stage of care, while helping reducing healthcare costs.