A Medical Neighborhood is an expanded patient-centered care model where primary care and specialty providers, hospitals and other clinicians work together in partnership to provide complete and coordinated care.
What are the core concepts in a Medical Neighborhood?
Practices participating in a medical neighborhood may focus on promoting population-based approaches, reducing duplication of diagnostic testing and procedures, and enabling the timely availability of clinical information to promote continuity of care – activities which are especially critical when the patient is transitioning between levels of care.
To ensure a well-functioning medical neighborhood, practices should also engage and educate their patients about what the medical neighborhood is, who the practice’s neighbors are, and what they’re responsibilities are. This is vital as patients are the primary communicators with most of the clinicians in their neighborhood.
Who makes up the Medical Neighborhood (i.e. providers, entities, etc.)?
Unlike a geographic neighborhood, a Medical Neighborhood is a set of relationships revolving around the patient and their health care needs.
Collaborating “neighbors” can include the primary care and specialty providers, as well as case managers, social workers, physical therapists and visiting nurses, the pharmacist, the laboratory, and the hospital.
In order to ensure that everyone knows what is happening with a particular patient’s care, interoperable electronic health records can be used to allow all providers to share information including diagnoses, medication lists, problem lists, lab results and care plans. In order to ensure that information flows beyond a particular “neighborhood’s” wall, state-wide or community-focused health information exchanges (HIEs) are quickly becoming a way for exchanging information beyond just one provider or health system.