Patient-Centered Medical Home (PCMH)

A Patient-Centered Medical Home (PCMH) is like a central hub for your health, where you and your care team work together as partners to manage your health needs. Your primary doctor orders all your care, so your team knows about your appointments with specialists, tests, and other services to make sure everything works together to keep you healthy. The relationship between you, your medical provider, and your care team is one of the driving forces behind a Patient Centered Medical Home (PCMH). YOU are the center of your own health care and should be an active participant by taking charge of your health and responsibly manage and monitor your own care. Some of the things you can do are:​

• Communicate openly with your provider and staff. Inform your care team of your medical history, health status, recent test results, self-care abilities, and information from recent hospitalizations, emergency, or urgent care visits.

• Inform us about medication or supplements you take on your own or had prescribed to you by other providers not in our office.

• Ask questions when information or instructions are unclear.

• Ask for help with issues you may face (financial, social, psychological, etc.).

• Give your personal health records to our offices so that your care team has all the necessary information they need.

• Be prepared and on time for your appointment and bring all your medication bottles with you.

• Cancel and reschedule appointments that you cannot keep.

• Set goals you want to meet in your individualized care plan and follow the care plan.

• Prepare your Advance Directives and give us a copy to keep on file. If you don’t know what these are or how to prepare one, ask to speak to our Medico-Legal Partnership department.

• Contact us for after-hours advice, in non-emergency situations, before going to the emergency room.

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Your medical provider will provide medical care that is right for you based on evidence-based clinical guidelines shown to improve health. Your care team is directed by your provider and is much more than your provider and nursing staff. At NHHC, staff from all departments work together for you and coordinate your care and services within NHHC and with outside healthcare providers and facilities.  We will:

• Deliver quality care that respects your unique desires and needs.

• Offer comprehensive health care services including primary care, dental care, behavioral health, laboratory, radiology, pharmacy, immunizations, social services, outreach and enrollment, and health education.

• Manage and coordinate your care over time.

• Communicate with internal and external providers/facilities to coordinate your healthcare across all specialties.

• Develop personalized care plans for each patient.

• Supply self-management support, tools, and educational resources to help you manage your health.

• Prepare for your appointment by reviewing your medical chart for care that is due and fill out up-to-date forms, tests, and specialists reports.

• Provide enhanced access (weekend, extended hours, 24-hour help lines) to appointments, clinical advice, and patient information.

• Proactively remind you about care and services when it is due or overdue.

• Guide you and your family to community resources and services.