Transforming Healthcare Begins at "Home"

"Change can be difficult, and evolving into a patient-centered medical home model is a completely new mindset for delivering care," says Mark Lamos, MD, an internal medicine physician at GBMC for more than 20 years and leader of the primary care physician side of Greater Baltimore Medical Associates (GBMA). But he stresses that this particular change is in the best interest of patients. "As we transform practices into medical homes, we will only see improvement in the health of our community,” he explains.

Dr. Lamos, along with the dedicated physicians, nurses and staff at the GBMC Hunt Valley practice, has developed and implemented the first medical home model for this practice and for GBMA. Among the significant changes he and his team have made are moving into an expanded office space, launching a new Electronic Medical Record (EMR) system, establishing care coordinator teams and extending office hours.

Operating as a medical home means added emphasis on evidence-based medicine to decrease risks and improve wellness for patients. By focusing on disease management, patients who are dealing with obesity and/or have diabetes or hypertension, for example, will have a team coordinating their care so that their condition, medications, even follow-up appointments, are all closely monitored and managed. This keeps the disease in check for the long term, which benefits the patient and saves the system from expensive emergency room visits and hospital stays.

Dr. Lamos states that if a physician refers a patient to a specialist, a care coordinator will verify that the patient went to the specialist. "We will also take other factors – like finances, mobility, language and cognitive skills – into consideration as we develop a treatment plan. It’s all about long-term, coordinated care to help our patients thrive.” He notes that implementation of the EMR system will ultimately make patient care more efficient, so that his team has time to guide patients to better health and to follow up with them.

Debbie Jones-Shook, MS, CRNP, CDE, nurse practitioner at Hunt Valley, describes the evolution to a medical home model as a change in both the providers’ and patients’ attitudes. Instead of the current transactional method of care in which doctor or nurse treats each occurrence of pain or illness, patients are now being included as active members of their healthcare teams. "The relationship is more collaborative, with providers educating patients on how to better manage current disease states, prevent future disease and strive for more healthful outcomes,” she says.

The employees of GBMC at Hunt Valley are a cohesive team that will continue to grow, learn and reinforce the medical home philosophy of patient-centeredness. Thus far, the transition has progressed smoothly, which Dr. Lamos and Jones-Shook attribute to the staff being very much like a family itself. They will be the first Greater Baltimore Health Alliance practice to become an accredited medical home site and will set the standard for all other GBMA practices, as well as private practice physicians.

As Dr. Lamos often says, "It’s no longer an individual system; it’s a patient-centered medical home. Home meaning that we’re all in this together.”