Medical Home

  • Baylor Scott & White Quality Alliance has the largest network, over 332 physicians, of National Committee of Quality Assurance (NCQA) recognized Patient-Centered Medical Homes (PCMH) in the nation.

  • NCQA-transpOur PCMH model was first designed by enhancing existing preventive health services and disease management infrastructures. Resources such as care coordination, advanced practitioners and decision support tools were augmented to achieve fundamental PCMH components of comprehensive, patient-centered, and coordinated care as well as accessibility, and quality.

    Patients in a BSWQA PCMH are paired with a dedicated primary care physician who agrees to be held accountable for providing comprehensive, quality care in a coordinated manner. The primary care physician guides a care team involving care coordinators, advanced practitioners, RN care managers, health coordinators and social workers to assist patients with emergency department and in-patient/post-discharge transitions, monitoring chronic conditions, identifying gaps in care, and promoting wellness. Care is coordinated across multiple care settings that may include hospitals, specialists, post-acute care, and community services.

    Transitioning our practices to recognized PCMHs has revitalized primary care delivery and prompted a renewed focus on the important role it plays in shifting from volume to value. As the largest network of NCQA recognized PCMH’s, we have improved quality and safety for our patients, while simultaneously creating a foundation for achieving the three-part aim. Through PCMH initiatives we have incorporated key elements of managing patient populations such as: evidence-based medicine, care standards, team-approach to care, expanded access, coordinated care, community care patient education, social work, preventive health, wellness, and disease management.