Wilmington Health Center is Delaware’s first multi-site Patient-Centered Medical Home

Wilmington Health Center is the first certified multi-site Patient-Centered Medical Home (PCMH) in Delaware, where primary care has been transformed into a system of care that can make people’s lives better.

That certification by the National Committee for Quality Assurance (NCQA) means that the Adult Medicine Office, Internal Medicine Faculty Practice and Pediatric Practice Program use evidence-based, patient-centered practices that focus on highly coordinated care and long-term relationships with patients who are partners in their care.

To the patients who rely on their Patient-Centered Medical Home, the model offers expert, respectful care from a team that includes a clinical pharmacist, health coach and social worker, in addition to doctors and nurses. If patients need extra help, team members partner with patients, families and the community to make certain they receive it.

Recently, a seriously ill woman turned to the Wilmington Health Center with a seemingly insurmountable mountain of issues. She was working but had lost her health insurance after a divorce. She earned enough to make ends meet, but not enough to pay for insurance or the $1,500-per-month medication she needed when she suddenly got sick.

The resident, Mahmudul Haque, M.D., examined the patient and immediately alerted the team to ensure there wouldn’t be a lapse in her medication.

“She had three days to go on this very expensive medication but was turned down for help from the drug company because she had an income,” said Linda Brennan-Jones, an outpatient social worker.

Within the hour, Carlette Dickerson, a pharmacy program coordinator, documented that the patient had run out of sick time and was no longer getting paid. The drug maker agreed to provide free medication, delivered within 24 hours.

Dr. Haque examined the patient and made arrangements for her to see a specialist later that day. Within two hours of her arrival, the patient had access to both medication and care. The next day, Dr. Haque followed up with her specialist for an update.

“Her case truly demonstrated the concept and execution of the Patient- Centered Medical Home model,” said Cheryl Jackson, M.D., the attending physician. “It was a prime example of coordinated, multidisciplinary care that wrapped its arms around the needs of the patient.”

On a recent afternoon, Brennan-Jones helped an uninsured patient with diabetes to apply for $400 in medical supplies from the Delaware Diabetic Fund. She is working to get him orthopedic shoes that will help prevent pressure wounds.

The patient was struggling to pay out of pocket for several medications. Pooja Dogra, Pharm.D, the clinical pharmacist, suggested several alternatives widely available at big box stores for $5.

The Wilmington Health Center achieved multi-site certification status in July, under the leadership of Sarah Schenck, M.D., Shirley Klein, M.D., and Dr. Jackson, practice coordinators, Lisa Wallace, APN, Melissa Crisconi, RN, and Crystal Pollock, RN, and Mary Theresa Lednum, BSN, RN-BC, center director. The center’s three primary care practices — Internal Medicine, Adult Medicine and Pediatrics — offer a continuum of care from infancy to old age.

“Creating innovative, affordable systems of care that our neighbor value is The Christiana Care Way,” said Julie Silverstein, M.D., medical director.