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Medical Home

The medical home model is a model or philosophy of primary care at that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. In the medical home model, the patient-provider relationship is of utmost importance, as the primary care provider works with the patient as well as with the patient’s family, to determine the most appropriate and acceptable plan of care. Through the implementation of the Medical Home, Lakewood Health System has taken on a patient advocacy role, both in the state of Minnesota, and nationally.



Medical Home program benefits at Lakewood include:

  • Individualized care planning, team approach and whole person orientation.
  • A coordinated team approach that allows doctors, physician assistants, nurse practitioners, nurses and ancillary personnel working at the highest level of their training—all for the benefit of the patient.
  • Patients are assured of swift communication and assistance, with care coordinated by their chosen medical home provider.
  • Pharmacists, therapists, educators, counselors, and home care nurses are able to communicate their recommendations in a timely, effective fashion, usually via the care coordinator.


Contact us if you have any questions about our medical home program!

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Common Questions

Medical Home is a new, innovative way to provide healthcare and is designed for patients with several chronic or complex health conditions. It takes an integrated, whole-person approach to health management, and involves a team of health professionals who work together to provide a more comprehensive type of care.

Medical Home provides patients with direct access to a team of registered nurses, or “care coordinators”, along with more immediate access to their personal physician and other healthcare providers as needed. Care is delivered in a team approach so that everyone on a patient’s “team” is kept informed and up-to-date on the health status of that patient.

The team will typically include a patient’s primary doctor, Medical Home care coordinators, a pharmacist, social worker, physical therapist, family members, caregivers, and specialists. The patient is considered a critical part of the team and is encouraged to play an active role in their ongoing care.

When a person is enrolled in Medical Home, they are given the direct telephone number and email address of our Medical Home care coordinators. Care coordinators are available Monday through Friday during regular clinic hours, and anytime after hours for urgent needs.

At Lakewood, we utilize a set of criteria to determine if someone’s healthcare would be best delivered within the Medical Home program. Those with multiple diagnoses (typically three or more requiring treatment), or who take multiple medications (usually four or more prescriptions) or those who have a severe or chronic illness like diabetes or heart disease, or an illness that requires frequent visits (every two months or less) typically fit the Medical Home criteria. Age is not a determining factor. Medical Home is available for anyone (children, adults, seniors) who meets the criteria.

There is no additional charge or fee for participating in Medical Home. The state of Minnesota and most insurers have agreed to pay a monthly fee to Lakewood for the patients they are insuring. Medicare in Minnesota has also agreed to pay for accredited patients being seen under the state of Minnesota criteria.

Talk to your medical provider, they will let you know if they feel you should be a Medical Home patient. They will then notify the care coordinators who will contact you. If you are not currently a patient at Lakewood, simply call to schedule an appointment with a doctor of your choice to establish care. Lakewood is a pioneer in the Medical Home movement and was one of the first in Minnesota to receive Medical Home Certification.