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Dome - The pinnacle of care delivery

March 2012

The pinnacle of care delivery

Date: March 5, 2012

Kudos for improving care delivery


Five primary care sites of Johns Hopkins Community Physicians have received recognition from the National Committee for Quality Assurance for successfully coordinating and managing patient care through an approach known as the “patient-centered medical home.”

 JHCP physician Scott Feeser, director of the medical home initiative, estimates that roughly 60,000 patients are benefitting from the program to improve care delivery. The Hopkins practices were awarded “Level 3,” the NCQA’s highest level of distinction.

The patient-centered medical home model focuses on preventing disease, reducing preventable hospitalizations and involving patients in their own care through a team-based approach. It works this way: Each patient sees a primary care doctor who heads a team that may include a nurse, pharmacist, social worker and nutritionist. Providers work together to offer patients easy, 24-hour access to care, either electronically or by phone. They also contact patients regularly between visits to see how they are faring and to reinforce any treatment orders. Success depends upon electronic medical records keeping team members up to date with each patient’s condition and progress.

Feeser helped launch the pilot project in 2009 at the Water’s Edge site in Belcamp, where he is medical director. It has since been implemented successfully at JHCP sites in Hagerstown, Rockville (Montgomery) and Baltimore (Canton Crossing and Wyman Park), all of which earned the NCQA’s Level 3 rating.

The model also encourages patients to participate more actively in their own care—whether it be to stop smoking or lose weight.

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