The Patient Centered Medical Home

Medical Practice / Office Ownership, Patient Centered care 6

Patient Centered Medical Home Goals and Outcomes

Fragmented Healthcare Delivery System

The medical model of patient care has become disconnected and fragmented, with research indicating growing healthcare disparities for chronic disease management outcomes. One of the goals of Healthy People 2020 is to eliminate disparities, achieve health equity and improve health outcomes in all populations. The Agency for Healthcare Research and Quality (AHRQ) promotes the medical home model as a means to transform healthcare organization and delivery. Providing a medical home that is centered on every aspect of patient care to improve health outcomes is the goal of The Patient Centered Medical Home (PCMH). The PCMH model utilizes a team approach within the primary care provider’s office to deliver comprehensive care with partnerships among all healthcare team members involved in the patient’s healthcare. PCMH promotes quality healthcare that is safe, affordable and more accessible for the patient.

The Patient Centered Medical Home (PCMH) Model of Healthcare

A PCMH is led by a healthcare provider who manages the medical home’s team. The patient’s medical home team centers the healthcare according to each patient’s individual needs with five attributes: comprehensive care, patient-centered, coordinated care, accessible services, quality and safety. Recognizing the patient and family members as significant members of the team, shared decision making is used in conjunction with the coordination of care with any healthcare team member involved in his or her care.

Primary Care Providers (PCPs) implementing the PCMH model provide accessible healthcare services which include enhanced office hours, decreased waiting times for urgent care needs, 24/7 electronic or telephone access to a team member, with alternative communication methods such as email. Patient centered care encompasses the entire aspect of healthcare across the lifespan: health promotion and disease prevention, acute care, management of chronic diseases, and end-of-life healthcare services. Coordination of care impacts the quality and safety of care, and is critical during transitioning from different sites such as hospital discharge to home or long-term care facilities. The PCMH team within the primary care provider’s office collaborates with the patient’s other healthcare providers within the community to ensure coordination of patient care and the patient is receiving appropriate follow-up that is both culturally competent and accessible. PCMHs are committed to quality and safe healthcare; therefore, evidence-based guidelines are implemented. Benchmarks are established for expected patient outcomes, with timelines to measure and report patient outcomes centered on quality and safety for each patient.

Envisioning Your Office as a Patient Centered Medical Home

In order for a practice to facilitate the Patient Centered Medical Home model, the AHRQ developed a manual Developing and Running a Practice Facilitation Program for Primary Care Transformation: A How To Guide. Supplemental educational webinars are available for healthcare providers and team members interested in the process of becoming a PCMH for their community. Research has indicated establishment as a PCMH does improve patient outcomes; however, it is a process that takes time, finances, determination and team effort.

National PCMH Accreditation

Recognition for a Primary Healthcare Provider’s medical office as a PCMH is voluntary. Practices desiring participation in a PCMH incentive program for assistance in becoming a PCMH may be required to participate in an accreditation or recognition program. Practices desiring PCMH will need to refer to their negotiation agreements with the PCMH incentive program, federal grant, participating accountable care organization (ACO) and major practice reimbursement payor, such as Medicaid and private health insurances. Many programs offering financial incentives require PCMH recognition from the National Committee for Quality Assurance (NCQA). Programs offering national PCMH recognition and accreditation include:


Considering establishment as a PCMH for your community will require determination of the electronic data and documentation requirements, as well as application and staff resource costs needed towards the journey of becoming a PCMH. However, in the end everyone benefits. PCMH improve patient outcomes by  providing individual patient-centered healthcare. Patients across the lifespan have one place to call their medical home for all healthcare services including healthcare promotion and disease prevention, acute care, chronic disease management and end-of-life healthcare. Health insurers benefit through the decreased healthcare costs, including decreased emergency room visits and referrals to specialists for care that can be managed within the medical home. Providers and the medical home team benefit knowing they are fulfilling their professional purpose and passion as they continue to actively pursue and maintain improved patient outcomes within their community.

Healthcare consumers interested in locating a nearby PCMH healthcare provider should contact their healthcare insurance provider to request a list of the healthcare plan’s participating PCMH providers, such as information provided through Horizon Blue Cross Blue Shield of New Jersey.

(This post was written as part of the Nurse Blog Carnival. More posts on this topic can be found at this month’s host, Big Red Carpet Nursing. Find out how to participate.)

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