CAPE MAY COURT HOUSE - A new program in Cape May County is promising to improve the care of patients through follow-up and coordination.

Cape Regional Physicians Associ-ates, which has 11 offices across Cape May County, is partnering with Horizon Blue Cross Blue Shield to launch the patient-centered medical home program.

Its goal is to coordinate the care of patients, particularly chronically ill people who often see a myriad of specialists and undergo multiple treatments.

To help doctors and specialists provide a continuum of care, the program relies on electronic health records that keep track of every medicine, treatment and doctor providing care to each patient.

The program also features patient care coordinators who steer patients through their treatment or recovery, said Joanne Vaul, of Stone Harbor, executive director of physician integration.

"With a patient-care coordinator, patients have a point person, someone they can contact with any questions. The coordinator reviews their progress on a regular basis to make sure they stay on track," Vaul said.

Cape Regional Physicians Associ-ates is a multi-specialty medical group affiliated with Cape Regional Health System. It has 41 medical providers, including 17 primary-care providers and 24 specialists.

Its electronic records are easily shared among the patient's primary-care doctors and specialists, the care coordinator and hospitals, regardless of where the patient is treated.

The ease of sharing these records prevents the needless duplication of tests, Vaul said.

Cape May County's summertime population explodes with second-home owners and vacationers. The coordinator helps provide a continuum of care to the patient even when he or she returns to places such as Pennsylvania or Florida, Vaul said.

Patient-care coordinator Jackie Hofmann, of Avalon, said patients with chronic conditions such as diabetes, high blood pressure or asthma stand to benefit from the improved coordination of care.

"We provide that extra added interaction to help them get on the road to good health," she said. "Instead of waiting for the three-month follow-up visit to the doctor, I'll call them and follow up."

This helps ensure the patient follows the doctors' orders and gives patients another opportunity to ask questions or get clarification on treatment instructions, she said.

Hofmann said the goal is to put high-risk patients at lower risk and provide early warnings to patients whose health is approaching a higher risk of conditions such as heart disease or diabetes.

"If they're borderline, we want to stop that before it goes any further," Hofmann said. "It's not just focused on the chronically ill. We make action plans that are meaningful for each patient."

The patient's primary-care doctor is the ultimate authority over the person's continuing care, Hofmann said.

"People need to rely on their primary-care physician. Otherwise, they're missing that preventive part. They're the gatekeepers," she said.

Vaul said she thinks the program will improve the collective health of Cape May County.

"The evidence supports that. It leads to a healthier community," she said. "We've recruited new specialists here and invested in electronic-health records. These are things we've done to show our commitment."

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