What is a Patient-Centered Medical Home?

What does it mean for you as our patient?

What we as your care team will do for you?

What we expect you to do for your own health?

A patient-centered medical home means that you will be surrounded by a dedicated team of health professionals; working together with you, to optimize your health goals using the best evidence-based medicine, education and resources available for you today, thus helping to empower you to take responsibility for your health and give you the self-management support you need to succeed.

Please note that we have a patient portal where you will be able to retrieve medical record access online!  Please contact Megan at (904) 861-1330 or via e-mail at contact@advancedpedcare.com to sign up today! Alternatively, you can sign-up for portal access at portal access. Further information can be found here.

The Practice believes that the Patient-Centered Medical Home is an excellent way to practice primary care medicine. The Practice’ mission is to help all children thrive in our community. As a Patient-Centered Medical home, the practice coordinates care across all care settings, including any care occurring at specialist visits, hospitals, emergency departments, urgent cares, home health settings, and health departments. This means we will work with the patient and the outside provider to obtain copies of any notes or results, and to help with scheduling appointments.

We follow the American Academy of Pediatrics Bright Futures schedule for well child care. A comprehensive health assessment is completed by the physician on all patients at each well child visit in accordance to Bright Futures (annually for children over 3 and more frequently for younger children). Age appropriate immunizations are assessed at each well child check at the 3 day old, 2 week old, 2 month old, 4 month old, 6 month old, 9 month old, 12 month, 15 month, 18 month, 24 month, 30 month, 3 year old visits and annually thereafter.

Family History (including mental health conditions and genetic disorders), Social History (including personal or cultural characteristics that could affect health such as refugee status or sexual orientation) and past medical history are reviewed at each well child check by the physician during the visit, and when relevant.

We assess communication needs at each well child care checks per Bright Futures, by assessing a combination of newborn hearing screening and parental perception of hearing in infants and then, starting at the 4 year well child check, and annually thereafter, using an automated hearing test.

As per Bright Futures, behaviors that affect health are assessed at each well child care checks as a part of anticipatory guidance.  Based on knowledge of the family risk factors, age of the patient, physical exam, vital signs and histories, the physician chooses the most relevant behaviors to assess.  Appropriate interventions are also considered (e.g. motivational interviewing based intervention for obesity or screening a sexually active teen for sexual transmitted infections using urine DNA tests).  See Bright Futures for a full menu of social determinates of health that are appropriate at assess at each age.

As per Bright Futures, a modified checklist for autism in toddlers (MCHAT) is completed by the family on each child at the 18 month well child care checks and 24 month well child care checks.  The physician scores any developmental screening and discusses the results with the family.  Similarly, an Ages and Stages questionnaire is completed during well child care checks at the 9 month, 18 month and 30 month old visits. These two types of developmental screens are meant to be in compliance with the Bright Futures recommended developmental screening program.

As per Bright Futures, all patients are screened annually for depression (using PHQ-9), as well as high-risk behaviors starting at the 11 year old well child check. The physician interprets these results and discusses results with the adolescent and if the adolescent agrees, with an appropriate care giver. Appropriate follow up or treatment is arraigned for any positive screen, such as medical treatment of depression, motivational interviewing based interventions for substance abuse, or referral to a developmental pediatrician.  Mothers of patients are also screened for post-partum depression at the 2-week-old well child care check using an Edinburgh Depression Screen.

We especially want to keep track and coordinate care for any mental health or behavioral health conditions or concerns. During visits, pediatricians provide basic counseling, including motivational interviewing techniques, and multiple forms of psycho-pharmacologic treatments. Our office assists families in coordinating care with psychiatrists, psychiatric hospitals, school-based counseling and psychiatric care, and outpatient family and individual therapies. All of these processes are detailed in the handout that each family receives when they join the practice and are detailed on our website.

Any advanced care directives (such as in patients with cerebral palsy) will be documented in the electronic health record.  It will be visible to anyone that opens the patient’s chart.

Each family is educated on upon entering the practice are the office hours; when and how to seek after-hours care, both within the Practice and preferred urgent care facilities; how to contact the physician and care team, both during and after office hours; and how families can obtain records from any other type of providers and have them sent to the Practice. Our practice seeks to obtain comprehensive patient information, including all medications, notes from visits to specialists, and all hospital and urgent care records. Often included in this information are any test results, health history, and health status from therapists or home health nurses.

When patients join the practice, the front desk care coordinators ask for the contact info of their former provider and we work to obtain medical records from the previous provider. Health care records may be obtained in the one of the following ways: by being forwarded from a previous physician, by being brought to us personally, or by a patient or caregivers verbally acknowledging the existence of such records so that we may obtain them.

The Practice’ physicians are up-to-date on all Continuing medical education, as mandated by the American Board of Pediatrics and by the Florida Medical Board. This assures families that they will receive evidence-based care from their medical team. A large part of our role is supporting self-management of the child’s health and health care, and to aid this we provide evidence-based educational resources for families, primarily using the American Academy of Pediatrics handout series.

The Practice works with most known insurance carriers in the area, including most types of managed Medicaid and non-managed Medicaid. We provide equal access to all patients, regardless of insurance status. As per our policy, uninsured patients are seen also on a fee-per service basis.  We also work with patients to create financial plans if the cost of care exceeds their ability to pay.

Our back-office staff can also help families arrange care through the state Medicaid program. We provide immunizations through the ‘Vaccines for Children fund’ for all uninsured patients or those who have any type of Medicaid. Our staff billing manager will talk with patients before or after a visit and explain how these policies, as well as state and national health care payment structures, applies to them individually.

Our practice is proud to be a Patient-Centered Medical Home. This means that the practice will work very hard to help our patients to have the best medical care possible. We ensure that our patients understand the Medical Home model by providing them with information on the what is a Patient-Centered Medical Home and what this means for them.

As your primary care provider, we will:

- Learn about your child, your family, life situation, and health goals and preferences.  Our team will recall your health history every time you seek care and will suggest treatments that make sense for you.

- Take care of any short-term illness, long-term chronic disease, and you or your child's all around well-being.

- Keep your child up-to-date on all vaccines and preventative screening tests.

- Connect your child with other members of your care teams (specialists, health coaches, etc.) and coordinate care with them as you or your child's health needs change.

- Find appropriate behavioral help as needed (including specialists, support groups etc.)

- Be available to you or your child, after hours, for urgent medical needs.  Our regular business hours are listed here. In case of urgent needs please call us at (904) 861-1330 or refer here. We are available for you 24/7 for any urgent medical needs.

- Notify you of test results in a timely manner.

- Communicate clearly so that all conditions and options are well-understood.

- Listen to your questions and feelings.  We will respond promptly to you, and your calls, in a way you understand.

- Help you make the best decisions for your care.

- Give you information about classes, support groups, or other services that can help you learn more about your condition and stay healthy.

- Help you understand your insurance options, should you be uninsured – all children deserve equal care to stay healthy, please contact Megan at (904) 861-1330 for more information.

We trust you, as our patient, to:

- Know that you are a full partner with us in your care.

- When you join our practice, you will provide us with a complete medical history and inform us if you obtained care outside of the practice.  Upon your first visit, we will have you complete new patient forms so that we may obtain all previous records your child may have.  Should you have any questions about this process, please contact us at at (904) 861-1330 or via e-mail at contact@advancedpedcare.com.

- Come to each visit with updates on medications, dietary supplements, or remedies you are using, and any questions that you may have.

- Keep scheduled appointments or call to reschedule as early as possible.

- Understand your health condition and what you can do to stay as healthy as possible.

- Work with us to develop and follow a plan that is best for your child’s health, if you have obstacles in fulfilling this plan, please discuss them fully with our staff.

- Use medications, as prescribed.

- Contact us, after hours, only if your issue cannot wait until the next work day.

- If possible, contact us before going to the emergency room so someone who knows your medical history can care for you.

- Agree that all health care providers in our healthcare team will receive all information related to your healthcare.

- Learn about your health insurance coverage either from your insurer, or, if you have additional questions about billing, you can contact us at us at (904) 861-1330 or via e-mail at contact@advancedpedcare.com.

- Give us feedback to help us improve our care for you.