Skip to main content
Off canvas

Care Coordination Helps St. Mark’s Family Medicine Earn PCMH Designation

Paige Fieldsted, Sr. Communications Specialist, HealthInsight Utah

St. Mark’s Family Medicine, led by Dr. John Berneike, has been working toward providing care coordination and patient-centered care for several years; making joining HealthInsight Utah’s Regional Extension Center patient-centered medical home (PCMH) Pilot program a logical next step.

“We fully believe in and are committed to patient-centered medical home as appropriate for patient-centered care and the foundation for the nation’s health care system,” Dr. Berneike said. “It’s not just about checking the boxes but actually providing patient-centered care.”

For St. Mark’s Family Medicine providing patient-centered care starts with care coordination and chronic disease management for their patients. Kelly Dowland, medical assistant with St. Mark’s, says that means contacting patients who are overdue for tests, who have chronic diseases that aren’t being managed well or who are frequently using the ER.

“We use self-management and self-care resources to help improve health literacy and help patients better control their conditions,” Dowland said. “We are providing proactive care, rather than reactive care. We reach out to them, rather than sitting back and waiting for them to come to us with a problem.”

St. Mark’s Family Medicine is just one of three practices in the PCMH pilot program that have received recognition from the National Committee for Quality Assurance (NCQA). St. Mark’s was recently awarded Level 3 PCMH recognition.

Berneike said that many of the processes needed to become a successful PCMH were already in place at St. Mark’s before the clinic began the pilot program but also said working with HealthInsight helped them improve their processes even more. Berneike also said that becoming a recognized PCMH was worth the effort the application process took.

Janet Tennison, the PCMH project manager at HealthInsight, said that St. Mark’s is one of the most innovative practices she worked with during the pilot program.

“They really get what health care should look like now,” Tennison said. “They are one of the most dedicated, committed clinics in terms of really improving patient outcomes and improving quality of life. They really care about their patients.

Tennison also said St. Mark’s is one of just a few practices in the state of Utah that is contracted to see refugee patients making the task of patient-centered care and care coordination even more daunting. Tennison said that providing services to refugees requires a whole other level of resources including dealing with cultural differences, the need for translation services and helping patients who have little to no experience with the health care system learn how to navigate the complex system.

St. Mark’s uses motivational interviewing to find barriers patients may be facing in managing their chronic conditions or to find out why they are overusing the ER. Dowland said that in order to be a true medical home, practices, physicians and medical assistants have to make a connection with patients.

“We are their medical home and we want them to take that term home literally,” Dowland said. “We want them to call home to make that connection anytime they have a medical need.”

Dowland and Berneike both said that helping patients take control and responsibility for their own care is key to being a successful PCMH and will benefit everyone in the end.

“We are helping patients to learn they have some level of responsibility for their care,” Berneike said. “We will help you, help yourself but it will also help the system. Better care equals more effective care and that helps everybody.”