The University of Delaware Nurse Managed Primary Care Center has been certified as a Patient Centered Medical Home, a designation by the National Committee for Quality Assurance recognizing practices that follow evidenced-based outcomes to deliver comprehensive, coordinated care and to improve overall practice efficiency in care delivery.

Patients and their loved ones who visit the nurse practitioner-led practice won’t notice anything different when they interact with staff through telehealth and in-person visits. And that’s exactly the point, said NMPCC Director Carolyn Haines. Patient-centered care has been at the core of the clinic from the beginning.

The certification follows more than five years of work to develop policies and protocols and also document collaborative outreach efforts that ensure clinicians are meeting the needs of their patients. The Nurse Managed Primary Care Center is one of 47 practices in the state with the PCMH certification and the only one led by nurses.

“It’s a big deal for a lot of reasons. Certification is a process that involves a lot of policies and reporting — and ingenuity — to make sure we can prove we are doing what we should,” said Haines, one of several nurse practitioners who sees patients. “The nursing students who spend their clinicals with us are seeing firsthand how the model of healthcare should look.”

Putting patients at the center

NMPCC handles about 6,000 patient visits annually, including primary care services, biomedical research testing and occupational health services, said Tanya Faison, practice analytics consultant.

As part of the certification process, NMPCC clinicians and staff looked at all measures of patient care, including access to service, referrals to specialists, chronic disease management, follow-up visits and patient education. Auditing existing policies provided an opportunity to enhance patient care where needed, Haines said.

From those internal reviews, the clinic staff created policies to focus on helping patients access the care they need for physical, mental and emotional health. That strengthened existing connections with UD programs, including the Speech Language Hearing Clinic, Delaware Physical Therapy Clinic, as well as services in nutrition counseling, exercise counseling and health coaching.

As part of a quality assurance project during the certification process, the clinic also searched patient records to see who hadn’t accessed preventive services such as mammograms, colonoscopies and pneumococcal vaccines. UD nursing students spending their clinical time in the clinic then sent out letters to those patients and followed up with calls to help with scheduling.

“Because of that we had more people integrated into their own care,” Haines said.

Meeting the needs

As care coordinator for the Nurse Managed Primary Care Center, Christine Smith played an integral role in the PCMH certification. Her work focuses on helping patients get the care they need, whether it’s making a specialist appointment for someone who can’t do it on their own, scheduling a follow-up at the clinic with a patient who was seen in the emergency department, or even adding a note to her personal calendar to check on a patient.

Smith said it is critical for her to know the clinic’s patients and understand whether their age, ethnicity, home life, educational level or language barriers may mean they require additional resources or services to get the level of care they need.

“If you have patients who speak Spanish, are your materials in Spanish? Does your patient have a telephone? If you give the patient a form about diabetes, are they going to be able to read that?” Smith said. “Those are all things we think about. It’s the comprehensive care that we offer plus the follow-up and the coordination. We go over and above for our patients.”

The clinic also has focused on improving care management for patients with chronic illnesses. Faison said the healthcare team began working closely with a small group of patients who have chronic issues like diabetes or hypertension that typically require more hands-on care. Clinicians and clinic staff created care management plans that identified potential hurdles to their care and ways to help patients overcome them.

Nationwide, about 13,000 practices are recognized as patient centered medical homes by the NCQA. The designation matters because Medicare and private insurers select providers for quality-based incentive payments based on the certification.

The Nurse Managed Primary Care Center is now scheduling both telehealth and in-person visits for patients who need care. The clinic is following all guidelines from the Centers for Disease Control and Prevention to minimize any potential for virus exposure. To make an appointment, call (302) 831-3195.