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Patient Centered Medical Home
patient_centered_practice.jpgYour primary care Doctor’s visits at Memorial Hospital of Rhode Island are being revolutionized – and are getting better and more valuable to you and your family. The Family Care Center at Memorial is changing the experience of patients’ care. Although the Center has over three decades of experience as a leading primary care provider for well over 10,000 community residents, clinicians continue to improve the practice of medicine. Over the past ten years, the Family Care Center has been moving to achieve a transformation in the care it provides – becoming a highly functioning patient-centered medical home.

The patient-centered medical home’s approach is to provide comprehensive, coordinated care to every age group – from infants to older adults.  The key to the medical home is having a team of healthcare professionals, headed by a physician, working with patients to form partnerships to maximize health outcomes. This team includes the physician, nurses, social workers, dieticians, pharmacists, physical therapists and others – all working together for the individual care of patients.

Physicians in the Family Care Center have personal responsibility and accountability for the ongoing care of their patients’ needs. The Family Care Center offers open access – “sick today, seen today”.  The health professional team also help patients make healthy lifestyle decisions and coordinate care with specialists, when needed; making sure procedures are relevant, necessary and performed efficiently. Quality and safety are hallmarks of the patient-centered medical home at Memorial.  For example, all your medications are reviewed at each visit, to make sure that there are no harmful interactions or mistaken dosages.

“The whole idea is to change the experience of care from something that is episodic – that you just see the doctor when you walk in the door – to an experience where a team is helping you to manage your own care 365 days a year,”
Jeffrey Borkan, MD, PhD, Physician-in-Chief of Family Medicine at Memorial Hospital.

Medical homes are changing the 1950s model of primary care – patient treated by one doctor - to a model where it is the patient, doctor and a team of professionals that will provide appropriate resources to you.

As an example, consider the following scenario:

You are diagnosed with diabetes. Your doctor at the Family Care Center will discuss it with you and coordinate a treatment plan. However, you need to learn to eat differently. A dietitian is brought in. You need to figure out how to inject your insulin or check your sugar. A nurse is brought in. You may have issues that arise with work, home and family. A social worker is brought in. As a patient, you have a nurse care manager that helps to coordinate all these pieces together. A patient goes to their appointments, coordinated care occurs and everyone involved is in communication about you and your care.

Each team in the Family Care Center has a physician, resident, nurse, social worker and ancillary staff and is supported by a nurse care manager, nutritionist and psychologist. In the hospital’s residency training, the emphasis of the patient-centered medical home is training the next generations of doctors with the focus on care teams and better patient partnerships. First, second and third year residents learn and live the principles of the medical homes. Diabetes and other group visits are run by family medicine residents with the team’s input.

The Center offers patients specialty clinics that include: acupuncture, gynecology / colposcopy, psychiatry, osteopathic manipulative medicine, family planning, suboxone, geriatrics, nutrition, high-risk obstetrics and pediatric neurodevelopmental. Patients also receive care from specialists in dermatology, psychiatry, psychology and social work.

The Family Care Center uses the latest information technology to prescribe, communicate, track test results, obtain clinical support information and monitor performance. At Memorial, it means increasing the use of preventive care and regular screenings and supporting people with diabetes, depression, coronary artery disease, smoking cessation and other chronic diseases and problems in new and innovative ways.

Memorial’s Family Care Center medical home is certified by the National Center for Quality Assurance (NCQA), the nationally accrediting body for the patient-centered medical homes. The NCQA worked with four national organizations representing approximately 333,000 primary care physicians – the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association – to develop a set of standards. Independent reviewers score the practice based on how well they meet NCQA standards. The Family Care Center at Memorial has reached Level 3 NCQA recognition, the highest level of recognition available under the program.

Rhode Island leads the country in the number of physicians per capita who are practicing in patient centered medical homes certified by the NCQA. The RI Chronic Care Sustainability Initiative (CSI-RI), a multi-stakeholder program organized by the state health insurance commissioner, includes all of RI’s based payers and Medicare, with Memorial Hospital’s Family Care Center being 1 of 13 primary care sites that functions as a patient-centered medical home.

Dr. Borkan continues, “Through CSI-RI, Memorial is getting access to expert resources and to colleagues with the same vision, doing the same kind of work. The goal of the patient-centered medical home in the Family Care Center is not to just transform primary care but to work with an entire medical neighborhood of specialists, hospitals and others to improve care that will better serve patients and communities.”

For more information on the patient-centered medical home in the Family Care Center at Memorial Hospital, call (401) 729-2304 or visit
Have a Question? Call 1-800-647-4362 to speak with our physician referral service


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