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Patient Centered Medical Home


(From left to right) Chris Schreckengost, Sarah Sullivan, Krissy Graham, Shannon Fors, Jessie Agnew, and Rachel Murray.“PCMH” isn’t just another acronym at Bozeman Health. It stands for Patient-Centered Medical Home, but more importantly, it represents a philosophy or model of care that embraces a team-based approach, care coordination, enhanced access, continuity, and more. The team of providers, nurses, pharmacists, social workers, care coordinators, and other staff work together to engage patients in their primary health care. The model is built on collaboration and relationships using an “all about the patients” or patient-centered approach.

Internal Medicine, Family Medicine, Family Practice, Pediatrics, and Belgrade Clinic are all part of the PCMH model; if a patient has a primary care provider in any of these areas, they are automatically part of Bozeman Health’s medical home.

The PCMH nurses are an integral point of contact for patients to reach out to with questions or concerns in order to achieve health and wellness goals. PCMH Care Coordinator Rachel Murray, RN, BSN, stated, “Internal Medicine reaches out to about 45 patients per day, and the majority of those we speak with are overwhelmingly appreciative of the follow-up phone calls and engagement in care.”

The PCMH team currently includes six care coordinators, comprised of five RNs and one LPN. They are able to arrange same-day appointments when needed, and provide regular reminders and follow up to keep patients up-to-date with vaccinations and screenings, such as mammograms and colonoscopies. They work to keep patients’ preventative care needs up-to-date, help manage chronic conditions, and coordinate follow-up care after ER/hospital visits. As a small team, they have a big job – assessing the whole-health needs of our patients, subsequently creating ‘homes’ for patients’ health care.

There are countless examples of how patient care has been enhanced through PCMH work. Bozeman Health started the PCMH journey in 2011, and thanks to the team and everyone involved we will continue to expand and transform the way we deliver care, and in doing so, improve community health and quality of life.

In the Photo (From left to right) - Chris Schreckengost, Sarah Sullivan, Krissy Graham, Shannon Fors, Jessie Agnew, and Rachel Murray.

Bozeman Health Medical Home Page

Medical Home Brochure

Categories: Simply Healthy