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Patient-Centered Medical Homes

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TeleHealth refers to a variety of virtual health care services we offer, and has become an integral part of our care model as we look to introduce new ways to access and deliver care to our local communities.

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NCQA NYS Patient-Centered Medical Homes

Bassett Healthcare Network strives to better the health of the populations we serve, as well as our patient's experience with us, by providing patient-centered coordinated care in our primary care centers. This effort has resulted in many of our primary care, internal medicine, pediatrics, and school-based health centers being recognized by the National Committee for Quality Assurance (NCQA) as New York State Patient-Centered Medical Homes (NYS PCMHs)!

To learn if your health center is a NCQA recognized PCMH, visit your location's webpage and look for the below logo:

NCQA NYS Patient-Centered Medical Home

What is a Patient-Centered Medical Home?

A patient-centered medical home is a medical office where a team of professionals work together to provide and coordinate your health care across multiple settings. Your medical home team includes your health care provider, others who support you, and — most importantly — you. You are the most important person on your health care team. Patient-centered is a way of saying that you are the focus of your health care.

Different members of the team will work with you to provide care and support within their areas of expertise:

  • Doctors, nurse practitioners, and physician assistants provide assessment and treatment.
  • Nurse care managers coordinate clinical resources to ensure safe, continuous care for you. They teach you and your family how to self-manage chronic conditions at home and coach you to achieve your desired health goals.
  • Registered nurses provide telephone advice and follow-up with patients by phone after a hospital stay.
  • Licensed practical nurses administer medications or vaccines and collect lab specimens as ordered by your clinician.
  • Medical office assistants will ask you questions about your medications, medical history, and other needed information.
  • Medical assistants and ambulatory office assistants provide general reception services, including answering phones, scheduling appointments, making referrals, and handling reminder phone calls or letters.

All staff work together as a team to help you stay healthy and get the care that is right for you.

Primary Care Services at Patient-Centered Medical Homes

Our primary care services include:

  • Treatment of minor illnesses.
  • Preventive care, including: wellness exams, immunizations, and screenings.
  • Referral to specialty services, including: behavioral health and substance abuse counseling and support.
  • Chronic disease management, including: diabetes, hypertension, and behavioral health conditions such as anxiety and depression.

We welcome all patients, and provide equal access to appointments, phone advice, and services regardless of payment source.

Learn More About What it Means to Receive Care at a Patient-Centered Medical Home

Click on the below dropdowns to learn more about what it means to receive care at a Bassett Healthcare Network patient-centered medical home:

There are many benefits of receiving care at a designated PCMH. For example, your medical home care team:

  • Knows you and remembers your health history. They know your personal or family situation and suggest treatment options that make sense for you.
  • Encourages you to play an active part in your own health care. Your medical home team will ask you to choose a wellness goal that is important to you and will work with you toward achieving it.
  • Listens to your concerns and helps answer your health questions.
  • Helps you coordinate your care for medical and behavioral health services and works with other health experts if necessary.
  • An on-call practitioner is available for clinical advice by phone after hours – 24/7. Call 1-800-BASSETT to speak with the on-call practitioner.
  • The practice is available electronically via MyBassett Health Connection for patients to get test results, and to request appointments, renewals, or ask for routine advice. The practice will respond to electronic requests during business hours.
  • Connects you to insurance specialists to assist you with questions and enrollment.
  • Informs you of our Community Services Financial Aid Program providing assistance to uninsured individuals and families unable to pay all or part of their medical care.
  • Assists you with transferring or obtaining your medical records to or from Bassett. You can contact your Primary Care office or the health information office by calling 1-800-BASSETT (1-800-227-7388).

At your PCMH, you can expect:

  • A care plan that is personalized and created just for you.
  • Answers to your questions to help you better understand your care needs.
  • Education for you and your family to help set and achieve goals to improve your health care.
  • Information about local and online resources to help you manage your health, including access to group education classes and support groups.
  • Preventive immunizations and screening tests.
  • Clinicians following evidence-based guidelines and recommendations for chronic conditions.
  • Electronic access to the practice to request appointments, renew medications, and ask for clinical advice.
  • Prescriptions to be e-prescribed to your pharmacy as part of safe medication prescribing.

Your PCMH team is here for you. Here are some tips on how you can best communicate with your care team:

  • Bring a list of questions to each of your appointments. Also bring a list of any over-the-counter medicines, vitamins, or herbal supplements you use.
  • Let your medical home team know when you are feeling sad, experiencing anxiety, or want to change unhealthy habits as part of our Behavioral Health program. Your primary care practitioner diagnoses and treats behavioral health conditions and will connect you to a behavioral specialist for counseling or medication management when warranted.
  • Share your medical history and tell your medical home team if you get care from other health professionals so they can help coordinate the best care possible.
  • Tell your medical home team when you don’t understand something. Ask them to explain it in a different way.
  • Talk openly with your care team about your experience getting care from the practice so they can improve their care and service for all patients.

PCMHs put you at the center of your care, and help you learn to be a partner in your own care:

  • Learn about your condition and what you can do to stay as health as possible.
  • As best you can, follow the plan that you and your medical home team have agreed is important for your health.
  • Sign up for MyBassett, so you can more easily communicate with your care team.