Norton Sound Health Corporation’s primary care system (care delivered in the outpatient clinic setting) was recognized as a Patient-Centered Medical Home (PCMH) in 2017 by the National Committee of Quality Assurance (NCQA). Please read the information below to better understand how your ongoing care, as well as your preventive care, will continue to be coordinated at NSHC.
The concepts of the Patient-Centered Medical Home include:
Concept 1: Team-Based Care and Practice Organization
NSHC has developed three Primary Care teams known as Tundra, River, and Mountain that are focused on patient-centered comprehensive care. Nearly all patients have been assigned to a team based on their home community and/or patient preferences. NSHC’s teams allow all staff to function at the top of their license and provide the best care to patients and families. If you are not certain which primary care team has been assigned to help you, please check your online MyHealth patient portal or call the Primary Care Clinic at 907-443-3333. Remember that you, the patient, are the central member of your care team.
Concept 2: Knowing and Managing Patients
To fully achieve whole person care, providers focus on the physical, behavioral, and psychosocial dimensions of patients, which requires an integrated care approach to behavioral health and primary care. NSHC utilizes data from and about its patients and communities to deliver high quality, evidenced-based care to all. This includes reaching out to you about preventative and chronic care needs you may have. NSHC also uses this data to help design and implement programs around the region to improve everyone’s health. This concept also includes making sure all programs are culturally and regionally appropriate for all of patients.
Concept 3: Patient Centered Access and Continuity
Being patient-centered means taking patients’ goals and preferences into account when designing services. NSHC has implemented changes based off feedback and data to help it become more patient-centered. It has started to extend hours for primary care appointments and has offered same-day availability for appointments in some of our communities. The goal is to make this available in all communities. The Nome clinic schedule is now open at least two months in advance to allow efficient follow-up scheduling. Historically, due to the size of this community, the schedule was not available in advance.
NSHC’s patient-centered approach also includes dedicating resources to disease prevention and management of chronic conditions. Through primary care teams, the goal is that patients feel more at home with more provider and staff continuity. Another key aspect of patient-centered access is providing in-home support to patients by bringing clinicians to the patient when needed. NSHC is working to expand services to include in-home chore and Personal Care Attendant (PCA) services. NSHC is recruiting for an in-home support registered nurse to oversee this expanding program.
Additionally, Behavioral Health consultants are located at the Patient-Centered Medical Home to provide brief assessment and Behavioral Health services in collaboration with the patient’s primary health care manager (PCM).
Concept 4: Care Management and Support
NSHC’s goal is to help plan for patient and community care needs in coordination/cooperation with patients/families. NSHC has dedicated resources to a new clinical service to ensure that the needs of patients are provided for. Primary Care prevention services are led by the new “Population Health” team. This team includes pharmacists, nursing providers and support staff with a goal of outreaching to ensure health and prevention needs are identified and met. For patients with ongoing care needs, NSHC Care Coordination services are:
List of NSHC Specific Care Coordination Services
Maternal Child Health Care Coordination: 443-3205
Contact: Anne Gollan, RN & Marla Mayberry, LPN
Pediatric Care Coordination: 443-3379
Contact: Deanna Jackson, RN, BSN, CEN
River Team (Unalakleet Sub-Regional Clinic) Care Coordination: 907-624-5444
Contact: Jackie Ivanoff, RN; Laverne Saccheus, RN; Anne Ivanoff, RN
Mountain Team Care Coordination: 443-3461
Contact: Cammie Hayward, RN and Theresa Olanna, RN
Tundra Team Care Coordination: 443-4561
Contact: Anna Moore RN, Dawn Coffelt RN, and Leslie Friedlob, RN
Specialty Care Coordination: 443-3267 *Patients may call specialty care directly or contact your primary care team coordinator listed above
Contact: Anita Helsius, RN
Concept 5: Care Coordination and Care Transitions
Patients experiencing emergency care, inpatient hospitalizations, and transitions between primary and specialty care require special care coordination. The establishment of case managers in the Emergency Department and inpatient unit, who work closely with the primary care team care coordinators, help make sure patients have the support they need in these transitions. Care coordination also means that we keep a close watch on tests (like labs and X-rays) and referrals to make sure they happen in an efficient manner.
Concept 6: Performance Measurement and Quality Improvement
NSHC was recognized for the second year in a row as a Health Center Quality Leader by HRSA for high quality health outcomes for the people of the region. NSHC staff is working together with patients to improve quality and performance, including improving overall patient satisfaction, improving service efficiency, and enhancing patient and family engagement. Primary care services meet monthly with leadership and patient representatives at Aquutaq (quality improvement committee meeting) to guide quality improvement and shape the clinical directions.