Outpatient Care: Family Medicine Center at BMC

The Family Medicine Center at BMC  is the Department of Family Medicine’s primary outpatient clinic. Led by medical director Dr. Christine Odell and associate medical director Alysa Veidis, NP, the Family Medicine Center is at the cutting edge of primary care delivery. Read more about the center’s various patient care initiatives below.

Patient-Centered Medical Home

The Family Medicine Center received level III NCQA Patient-Centered Medical Home certification in December 2013.   The patient-centered medical home model emphasizes:

  • Comprehensive team-based care
  • Enhanced access to care
  • Systems-based approach to quality and safety
  • Care that is coordinated
  • Behavioral health integration

Since beginning its patient-centered medical home transformation in 2011, the Family Medicine Center has made remarkable strides in shifting how it provides primary care for its patients. These initiatives are described in detail below.

Behavioral Health Integration

  • In our integrated care model, PCPs and behavioral health providers work together in the same place to better serve our patients’ needs.  Studies have shown that this model leads to improvement in depression, chronic disease outcomes, mortality, and health care costs.  All patients are screened on-site for depression and substance abuse disorders.
  • Our behavioral health team includes:
    • Patient Navigator to help match patients with resources
    • LICSW for short-term mental health and substance use counseling
    • Behavioral Heath NP for ongoing therapy and medication management
    • Psychiatrist for oversight, PCP education and direct patient care (high risk)

Read more about Behavioral Health Integration at the Family Medicine Center in one of the team’s posters, presented at the 2014 AAFP meeting in Washington, D.C.

Open Access

  • The open access plan is our approach to providing care to our patients by doing today’s work today. We can achieve this by being available for patients to get the care they need when they want it, ideally within the same or next day with their PCP or Team provider.

The idea behind open access is to keep up to 60%-70% of all appointments open up until 1-2 days prior to that day. Instead of scheduling weeks and months ahead (except for planned return care) patients will have access to their provider for care when they need it, be that today, tomorrow or the day after. Most patients want to have their concerns taken care of as soon as possible and pushing appointments out later and later increases no-show rates, reduces patient satisfaction and often lengthens appointments as patients feel the need to bring in their “list” of issues due to the length of wait to be seen.

Care Management

The Family Medicine team has designed a comprehensive 3-tiered care management model which allows patients to move along the care management spectrum as their health changes. All patients are eligible for population management (ensuring routine health maintenance needs are met); patients living with chronic diseases are engaged by the RN team for care management (for patients with 1-3 chronic diseases who need extra support coordinating their care); and our most  vulnerable patients with multiple chronic diseases have care managed on routine basis by NPs. The core care management model is supported by the medication management program with the clinic’s pharmD and the depression care management program run by clinic’s behavioral health NP and psychiatrist.

Read more about our PharmD’s successes managing diabetic patients here.

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