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Sixty-six year-old Frank Morgan* has congestive heart failure, diabetes, high blood pressure and sleep apnea. His wife Millie* is recovering from a stroke that is causing her persistent issues with coordination and balance. The two live independently in a small apartment in Frederick. Their financial situation is limited, neither drives, and none of the couple’s three children lives locally.
Dr. G. Johnson Koilpillai and his staff at the Parkview Medical Group have formed a “care team” to take care of the Morgans. Dr. Koilpillai sees the couple regularly, and the rest of the staff helps coordinate their care according to the plan the group has developed specifically for them.
This includes talking with them to address any barriers they face in carrying out their end of the care plan, including connecting them with community resources to explore transportation options and afford their medications. Keeping in touch with the other providers involved in the couple’s care helps avoid unnecessary duplication of diagnostic tests, and gives Dr. Koilpillai the most complete picture of their overall health.
The care the Morgans receive through Dr. Koilpillai and his staff at the Parkview Medical Group represents a promising approach to delivering primary care known as the “patient-centered medical home.” In a medical home, each patient has a primary care provider who leads a team of professionals such as a dietitian, social worker, pharmacist and referral coordinator who work together to provide patients with more complete information, better support and expanded access to care. Locally, more and more primary care practices are embracing the medical home, to offer patients more coordinated health care.
FMH in Top Tier for Use of Information Technology
Dr. Koilpillai says that the ability to share health information securely across multiple settings and caregivers is an important tool in coordinating a patient’s care. FMH recently completed its adaption of the Electronic Medical Record (EMR), and is in the process of assisting local physicians’ offices—including Parkview Medical Group– to do the same. Based on this and other IT benchmarks the hospital has achieved or exceeded, the Health Information Management Systems Society has awarded FMH with Stage 6 status, placing it among the top 2 percent of comparably sized hospitals nationwide.
* Names changed to protect patients’ privacy.