At State of Franklin Healthcare (SOFHA), we are continually searching for ways to improve services to our patients. We are pleased to share with you our program that has been designed to provide more advanced personalized health care services. This program is entitled "Patient Centered Medical Home" or PCMH. The PCMH was developed to enhance care by enabling our patient’s personalized medical access provided by a care coordinator under the direction of their primary care physician.
A medical home is where the primary care physician leads a professional health care team that will be responsible for the ongoing care of the patient. Patients are encouraged to self-manage their conditions through shared goals, education on disease states, and health coaches. The goal is to create partnerships between patients and their primary care physician. There is no additional cost to patients, just a signed agreement between the primary care physician/ physician extender and patient to participate.
This program is being conducted at SoFHA for patients with certain chronic disease states such as diabetes. If you are someone with a chronic disease state, you may qualify for participation in this program.
Our first effort at SoFHA in the PCMH is focusing on diabetes. Patients participating in the PCMH have available and will be provided with the following: educational tools on their specific disease states; receive one-on-one assistance with their care coordinator on their specific disease state; assistance in scheduling appointments and referrals; receive proactive healthcare services; assistance in making same day "urgent" appointments with their personal physician or a member of his/her healthcare team. Patients enrolled and participating in PCMH will have access to their personal care coordinator via e-mail and phone Monday -Friday 8:00am-5:00pm during operational business hours. The care coordinator will assist patients by triaging (determining medical priority) for same-day appointments with physician/physician extender. The care coordinator will follow-up with patients on a monthly basis for any needs or assistance in areas that may help in maintaining compliance with their on-going health care plan. Our medical team will assist patients in managing chronic disease states by providing education and ensuring any tests relevant to a particular disease state is performed as needed. In addition, patients will be provided with education related to preventive health screenings and any assistance with scheduling these screenings.
We at SoFHA want to provide you with the highest level of care possible and we feel this program will allow us to enhance your care by involving "you", the patient, in all areas of your health care.