POPULATION MANAGEMENT

Following current clinical evidenced-based guidelines, our practice runs frequent reports in an effort to close gaps in care and ensure a focus of improving the quality of care for our patients. These reports are meant to capture the attention of members of our patient population who have not yet received various services, tests, screenings, vaccinations, etc.

Our staff places reminder calls, sends reminder letters and utilize the patient portal in an effort to alert patients that they are due for services. At regular intervals, we will run reports from our electronic medical record and then that data is reviewed for accuracy before reminders are sent. We also send reminders for the flu vaccine, pneumonia vaccine, mammograms, colonoscopy, and overdue appointments via the patient portal and mail.

PATIENT-CENTERED MEDICAL HOME

Clarke Family Medicine is certified as a Patient-Centered Medical Home Practice for our patients.

What is a Patient-Centered Medical Home?

  • It is a team approach to providing total health care for you at our office for you. Your Medical Team consists of Dr. Ronald Clarke, Dr. Ryan Clarke, and Rebecca Sheehan R-PA

Who is part of your Patient-Centered Medical Home team?

  • Your health care provider
  • All other staff at your health care provider’s office
  • 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.

What do you need to do as part of your patient-centered medical home team?

  • Keep your medical home providers informed!
  • Let your health care provider know about care you receive from other health care professionals outside of our practice
  • Please work with your health care provider to provide your complete medical history
  • Call your medical home with any questions about your health and appointment requests before you go to an Urgent Care Center or Emergency Room!
  • Call our office at (716) 297-1027 during regular business hours as follows:

Monday 8am to 5pm

Tuesday 8am to 4pm

Wednesday 8am to 5pm

Thursday 8am to 5pm

Friday 8am to 4pm

  • After Hours and on Weekends call (716) 297-1027 for our answering service
  • Let your medical home know if you have been in the hospital. Call your provider as soon as you are discharged to set up appropriate follow up visits
  • Let your medical home know of any change in your medications after a hospital stay or from a visit with another health care professional
  • Bring all of your medications (or a list of your medications) with you to each visit
  • Take an active role in your own health
    • Follow the health care plan that you and your team agreed on
    • Set goals that you can reach. Once these goals have been reached discuss new goals
    • Tell your team if you are having trouble staying with your care plan or it is not working for you

What can your Patient-Centered Medical home do for you?

  • Help you manage your health care – taking into consideration the WHOLE package, including but not limited to: medical, physical, social, and behavioral health needs
  • Help answer all your health questions
  • Listen to your concerns
  • Coordinate your care if additional services are needed, including setting up care with medical specialists, behavioral health specialists, and at other facilities
  • Provide you with tools such as educational material or other literature to assist in your self-management of your or your family member’s health using evidence-based guidelines
  • Encourage you to play an active role in your own health
  • Assist you with HealthCare Coverage
  • Please reach out to the office at (716) 297-1027 or access your patient portal for any medical record needs in either transferring or receiving records