Becoming Our Patient

My Neighborhood Care…Care Centered Around You

NFP has always believed that partnering with a patient is the best way to achieve healthy outcomes and has been able to do so in a variety of ways throughout its history. NFP has always modeled its program offerings to serve patients in a comprehensive way. NFP sees that the services provided to patients are each just one stop in a constant continuum of care that envelopes every patient into their own medical home. For the past several years, NFP has been working on a model to transform its service delivery into a Care Team and EMR driven approach to Patient Centered Care.

NFP has set the following goals for its Patient Centered Medical Home:

  • Improvement in patient engagement

  • Improvement of patients’ health status

  • Improvement in patient satisfaction

  • Increased efficiency

NFP works to accomplish these goals through its use of patient-centered Care Teams. NFP’s care teams are usually made up of 2-3 providers, 2 nurse, 2 medical assistants, and a patient advocate. Comprehensive team formation, training, and ongoing development has taken place to develop this model at NFP. It has been demonstrated that patient engagement that leads to improved health status cannot be achieved by the medical provider alone, but through a well-organized team with identified roles and clear objectives. Through a more personal and trusting relationship between the patient and their care team, patients will be more likely to seek care and advice, see their primary care giver when indicated, and follow recommendations that can lead to improved health status.

NFP has been delivering mental health services to patients with depression, bipolar and anxiety disorders for over 17 years. NFP’s uses its team model of care within its integrated behavioral health services. The behavioral health department collaborates with NFP's primary health care providers to provide comprehensive care including universal depression screening for all adult patients and "warm hand offs" where patients are provided immediate care with behavioral health staff.

Ancillary members of the NFP Care Teams include a Clinical Pharmacist, a Wellness Coordinator, Patient Advocates focused on Women’s Health and Patient Engagement with Technology, as well as a team focused on services to newly arrived Refugees.