Medical Home: a new approach to total health care



Team approach

Early on, you and the RN Health Coach develop a care plan. The Medical Home team includes you, your provider and RN health coach as well as other health care professionals and staff at our clinics. Your team may also include trusted family and friends who you have chosen to play a role in your health care.

Is Medical Home right for me?

Talk with your RN Health Coach to learn more about Medical Home and if it is right for you.

You and your family would benefit from this service if you have:

    • Chronic illness
    • Multiple illnesses
    • Unstable or newly diagnosed illnesses
    • Multiple medications
    • Special Health Needs

The benefits of Medical Home

    • Your primary care provider partners with you and your care team to help manage and organize care, reducing stress for you and your family.
    • You and your primary care provider discuss your treatment options together and coordinate care with other experts.
    • You are treated as the central member of your health care team and your cultural and religious beliefs are valued.
    • You and your primary care provider share mutual respect and trust.
    • You are given information to help you learn more about your ongoing health concerns and address issues sooner, resulting in less ER visits and hospital stays.

Expect the best with Medical Home

    • Personalized Care: Our staff knows you and your family and how to treat you. When you call and say you're a Medical Home patient, we know exactly what is involved.
    • Access: With Medical Home, you have the access you need to your team and appointment times. If specialty care is needed, we quickly arrange it.
    • Support: The Medical Home RN Health Coach can connect you with helpful services, agencies and resources in the community. Connection will lead to empowerment for you.
    • Respect: Support comes from many sources. We respect every family's cultural and religious beliefs.

Words to know

Medical Home team or care team: a group of health care professionals who plan and deliver patient care in a coordinated way in collaboration with a patient. The care team includes at least one primary care provider, a RN Health Coach and may include other health professionals based on the patient's needs.

Primary care provider: a physician, a physician assistant, or an advanced practice nurse, such as a nurse practitioner or a clinical nurse specialist.

Care coordination: a team approach that engages the patient, the primary care provider, and other members of the care team to enhance the patient's well-being by organizing timely access to resources and necessary care that results in continuity of care and builds trust.

Care plan: an individualized document, including an electronic document, to guide a patient's care.

To learn more about Sanford Clinics Medical Home Program in Fargo call (701) 234-6918 and in Bemidji call (218) 333-5000.

To learn more about the Bismarck region of Sanford Health visit bismarck.sanfordhealth.org/familymedicine.

Posted Date: November 2011

Medical Home:  a new approach to total health care

Learn more about Medical Home