It had been several months since Luis had had a primary care visit at Gouverneur Healthcare Services. He had lost his job and health insurance. He assumed he could no longer see his doctor, and had not been able to buy medications.

Then he got a call from a friendly voice: “How are you? We have not seen you for a while.” It was the patient care associate at Gouverneur calling.

“With this routine call we let Luis know that we really care about his well-being and that he’s always welcome here – his medical home,” said Dr. David Steven, Director of Medicine at Gouverneur. “If we did not look out for him, his health could have deteriorated and he could have easily ended up in one of our emergency rooms with worse complications.”

But as part of the patient-centered medical home approach to care, Gouverneur closely tracks patients like Luis who have chronic illnesses and have gone too long without a visit. Luis got connected to his doctor again, and was also able to receive support from a social worker and other doctors to help address his new symptoms of depression caused by his unemployment.

“Our goal is to build personal connections with patients to provide primary and preventive care that can improve their health and reduce potential long-term costs,” added Dr. Steven.

After years of investing in preventive health services, electronic medical records, and better care management for chronic disease patients, 17 HHC facilities, including Gouverneur, secured the official Patient-Centered Medical Home designation granted by the National Committee for Quality Assurance (NCQA).

Now more than 600 physicians at HHC’s 11 hospitals and its six large community health centers are designated medical home practices for more than 477,000 New Yorkers who receive primary care services.

“To be truly patient-centered, we have to work more collaboratively and efficiently,” said Amanda Ascher, M.D., Medical Director, Segundo Ruiz Belvis Diagnostic and Treatment Center in the Bronx. “For example, our patients no longer need to wait for a doctor’s appointment to get their prescription refills. Now nurses can review the charts and make all the checks needed before the doctor approves the refill. When you can do this for 30 patients, you save 30 visits, many hours of unnecessary travel and wait time for the patient, and can ensure providers use their time more efficiently and spend it with patients who really need it.”

To receive the NCQA designation, HHC had to meet a number of safety and quality standards. Each physician practice had to demonstrate the hallmarks of a medical home: an ongoing relationship with a primary care doctor; a group of individuals who collectively take care of the patient’s needs across all healthcare settings; the use of electronic medical records; and the ability to offer access during evenings and weekends.

All of the HHC facilities received “Level 3” designation, the highest ranking, which will qualify HHC for more than $15 million in Medicaid reimbursement rate increases every year.

“The supplemental payments that will now be directed to support this work are a welcome reward for doing what we know is right for our patients,” said HHC President Alan D. Aviles. “It is ultimately a front-end investment to help us keep patients healthy and avert future costs to treat illness and long-term complications.”

Visit our website to view a complete list of HHC hospitals and community health centers designated as Patient Centered Medical Homes.