Defining the PCMH
Patient Centered
Medical Home
The medical home
model holds promise as a way to improve health care in America by transforming
how primary care is organized and delivered. Building on the work of a large
and growing community, the Agency for Healthcare Research and Quality (AHRQ)
defines a medical home not simply as a place but as a model of the organization
of primary care that delivers the core functions of primary health care.
The medical home
encompasses five functions and attributes:
1. Comprehensive
Care
The primary care
medical home is accountable for meeting the large majority of each patient’s
physical and mental health care needs, including prevention and wellness, acute
care, and chronic care. Providing comprehensive care requires a team of care
providers. This team might include physicians, advanced practice nurses,
physician assistants, nurses, pharmacists, nutritionists, social workers,
educators, and care coordinators. Although some medical home practices may
bring together large and diverse teams of care providers to meet the needs of
their patients, many others, including smaller practices, will build virtual
teams linking themselves and their patients to providers and services in their
communities.
2.
Patient-Centered
The primary care
medical home provides primary health care that is relationship-based with an
orientation toward the whole person. Partnering with patients and their
families requires understanding and respecting each patient’s unique needs,
culture, values, and preferences. The medical home practice actively supports
patients in learning to manage and organize their own care at the level the
patient chooses. Recognizing that patients and families are core members of the
care team, medical home practices ensure that they are fully informed partners
in establishing care plans.
3.
Coordinated Care
The primary care
medical home coordinates care across all elements of the broader health care
system, including specialty care, hospitals, home health care, and community
services and supports. Such coordination is particularly critical during
transitions between sites of care, such as when patients are being discharged
from the hospital. Medical home practices also excel at building clear and open
communication among patients and families, the medical home, and members of the
broader care team.
4.
Accessible Services
The primary care
medical home delivers accessible services with shorter waiting times for urgent
needs, enhanced in-person hours, around-the-clock telephone or electronic
access to a member of the care team, and alternative methods of communication
such as email and telephone care. The medical home practice is responsive to
patients’ preferences regarding access.
5.Quality
and Safety
The primary care
medical home demonstrates a commitment to quality and quality improvement by
ongoing engagement in activities such as using evidence-based medicine and
clinical decision-support tools to guide shared decision making with patients
and families, engaging in performance measurement and improvement, measuring
and responding to patient experiences and patient satisfaction, and practicing
population health management. Sharing robust quality and safety data and
improvement activities publicly is also an important marker of a system-level
commitment to quality.
AHRQ recognizes
the central role of health IT in successfully operationalizing and
implementing the key features of the medical home. Additionally, AHRQ notes
that building a primary care delivery platform that the Nation can rely on for
accessible, affordable, and high-quality health care will require significant workforce development and fundamental payment reform.
Without these
critical elements, the potential of primary care will not be achieved.
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