Learning more about the Primary Care Medical Home Model (PCMH)

The Primary Care Medical Home, or Patient Centered Medical Home is a model for transforming the organization and delivery of primary care. The Agency for Healthcare Research and Quality (AHRQ) defines a medical home not only as a place but as a model of the organization that delivers the core functions of primary health care.

The medical home incorporates five functions and attributes:

Comprehensive Care

• Meeting most of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
• The team of care providers may include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.
• Many smaller practices build virtual teams connecting themselves and their patients to providers and services in their communities.

Patient-Centered

• Provides health care that is relationship-based and actively supports patients in learning to manage and organize their own care at the level the patient is comfortable with.
• Patients and their families are also members of the care team and therefore are informed partners in creating care plans.

Coordinated Care

• The PCMH coordinates care across all aspects of the health care system, including specialty care, hospitals, home health care, community services and supports.
• Creating clear and open communication among patients and families, the medical home, and members of the larger care team.

Accessible Services

• Responsive to patients’ preferences regarding access.
• Gives available services with shorter waiting times for urgent needs, improved in-person hours, 24/7 telephone or electronic availability to a member of the care team, and alternative methods of communication like email and telephone care.

Quality and Safety

• Public sharing of quality and safety data and improvement activities is an important indicator of a complete commitment to quality.
• Dedicated to quality improvement by engaging in activities like using evidence-based medicine and clinical decision-support tools to advise decisions with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management.

Tools and resources to help implement PCMH

The Primary Care Practice Facilitation (PCPF) Curriculum: supports the development of the workforce that is prepared to help transform primary care by supporting a widespread adoption of the new models of care delivery and the use of continuous quality improvement. It is used to train both new and experienced practice facilitators in the knowledge and skills needed to support meaningful improvement in primary care practices.

Foundational Supports for the PCMH Model:

The Agency for Healthcare Research and Quality (AHRQ) also recognizes the central role of health IT in being able to successfully implement the medical home.

Health IT

• Can support the PCMH model by collecting, storing, and managing personal health information, and aggregate data that can be used to improve processes and outcomes. It can also support communication, clinical decision making, and patient self-management.

Workforce

• A primary care workforce including physicians, physician assistants, nurses, medical assistants, nutritionists, social workers, and care managers all trained in providing care based on the elements of the PCMH, is an important factor in the model.

Finance

• Current fee for service payment policies are incapable of fully achieving the PCMH goals.
• Payment reform is needed to achieve the potential of primary care and the medical home.