Medical home concept uses team approach to focus on staying well

MORGANTOWN, W.Va. – West Virginia University faculty members are leading a number of efforts to apply the concept of a “medical home” to patients who turn to WVU Healthcare physicians for care.

The medical home strategy identifies the patients most at risk for medical complications or hospitalization and concentrates the efforts of an entire team of health professionals on keeping them healthy.

“In the medical home, you are a part of our practice,” Karen Fitzpatrick, M.D., medical director of the Clark K. Sleeth Family Medicine Center, said. “Your healthcare is delivered by a team that’s working together to give you the support and tools you need to improve your health. We train everyone in the office who interacts with a patient that they own that patient’s care and their outcomes.”

The medical home team provides extra support to patients after a hospital stay. Patients are signed up for a visit to the clinic before leaving the hospital. There, they meet with all the members of their medical home team and are set up for a customized follow-up plan that can include multiple appointments and phone check-ins.
Recent initiatives by both private insurers and government programs under the Affordable Care Act now reward caregivers whose good work results in good health.

Elaine Markley experienced the benefits of a medical home firsthand.

Markley, an active 79-year-old from Huttonsville, W.Va., was rushed to Ruby Memorial Hospital from an emergency room in Elkins, W.Va., because of a blood clot in her lungs. Her doctors restored her breathing, but the incident severely worsened her diabetes.

A week after she left the hospital, Markley came for a follow-up appointment at the Sleeth Family Medicine Center. She had a few questions she hoped to get a chance to ask.

She was surprised to see her doctors from Ruby, a case manager, a pharmacist, and someone to talk with her about monitoring her blood sugar.

“I don’t even remember them all now,” she said. “I’ve never seen that many people at one appointment before.”

Case manager Lisa Metts, R.N., saw Markley every two weeks after she left the hospital, monitoring her blood thinner medication and diabetes. She set her up with home-test equipment so that she could get her medications checked without a trip to either Elkins or Morgantown. As Markley stabilized, the visits were tapered off, but Metts still calls every month to check up on her.

“I had a lot of questions,” Markley said. “And sometimes, when you have a doctor’s appointment, you forget to ask something, or you think you’re wasting the doctor’s time with a silly question. They never made me feel that way.”

Eventually, Markley’s medication was under control, and she had learned to give herself insulin shots and call in test results to the team in Morgantown. She hasn’t been back to the hospital. She has resumed doing the things she loves, including spending as much time as she can with her granddaughter, Abigail Elaine.

For more information about medical home, including a video, see the online version of the Fall 2013 edition of WVUhealth magazine at http://wvuhealth.hsc.wvu.edu.

Photo caption: Elaine Markley (right) has her blood drawn at WVU’s Clark K. Sleeth Family Medicine Center.


For more information:
Amy Johns, Director of Public Affairs, 304-293-7087
bc/sf: 12-02-13

Return To News Releases