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Annual Conference Highlights Primary Care Connecting Ohioans with their “Medical Neighborhood” to Improve Health

Did you ever go to the doctor and get told that you needed to lose weight for your health? If it were that easy to lose weight, no one would be overweight.

Imagine if your primary care practice asked you if you were interested in losing weight, told you that you were at risk for developing diabetes if you didn’t, and then offered to help you, by suggesting you try a program in your neighborhood that could help you.

Those are some of the benefits of a “patient centered medical home” (PCMH) model of primary care. And that’s what Ohioans can look forward to if Ohio achieves its goal of expanding this new, improved form of primary care to most Ohioans in the next five years. (Learn more about the PCMH model from this video). Primary care providers of the future will be paid to improve patients’ health, instead of getting paid for visits and procedures.

That’s one of the differences between much primary care today and the PCMH model of primary care. As the name implies, the PCMH is centered around the needs of each individual patient. The PCMH offers 24/7 access by phone or email, same day appointments when you’re sick, and a team that may include a doctor, nurse, someone to coordinate all your care (such as specialist visits), and more.

The annual conference of the Ohio Patient Centered Primary Care Collaborative, on October 30 in Columbus, addressed how the PCMH can connect with the “medical neighborhood,” which includes non-medical resources in our communities. The “medical neighborhood” is not only medical providers, such as specialists and your pharmacist, but also community resources that can make you healthier, such as recreation centers, cooking classes, and food pantries.

The keynote speaker, Katie Adamson, from the YMCA of the USA, described how the Y worked with the U.S. Centers for Disease Control to test a Diabetes Prevention Program (DPP). The results were so successful that they’ve taken DPP to Y’s across the nation, including Ohio. The Y’s program helps people make better food choices and increase their exercise, leading to weight loss and better health. People are more likely to join this or other programs to improve their health if their doctor recommends it. That’s why the primary care practice needs to be part of the medical neighborhood. Click here to find a Y program near you.

For providers to help their patients become healthier, they need to understand all of the factors outside the medical office that impact our health – where we live, what we eat, what kind of stresses we have (such as paying the bills and putting food on the table). That’s why David Norris of The Kirwin Institute for the Study of Race and Ethnicity at OSU and Chip Allen, Director of Health Equity at Ohio Department of Health, addressed the conference about the impacts of health inequity and social determinants (such as access to resources, educational and job opportunities, etc.) and strategies that can improve health outcomes. The medical home, if connected to a wide range of resources in the “medical neighborhood,” can refer patients for help with housing, food, legal issues, and other barriers to good health.

Many Ohioans facing a host of challenges in their lives need help getting both medical and non-medical services they need. Providing people at risk for poor health with care coordination from a trained navigator can make a huge difference in health outcomes, for pregnant women and people with chronic health conditions. Judith Warren, CEO of Health Care Access Now in Cincinnati, described for the conference participants a promising model for providing community-based care coordination services for patients in primary care. The Pathways Community HUB model uses community health workers to work with the medical/clinical team to help people at high risk for complications of chronic illness to keep out of the hospital and get healthier.

Regional collaboratives in Columbus, Cincinnati, Cleveland, and other cities are working to expand the PCMH model of care. To find a PCMH near you, click here or call UHCAN Ohio at 614-456-0060 x237.