The Patient-centered Medical Home (PCMH) is a model of care that puts patients at the forefront of care. PCMHs build better relationships between patients and their clinical care teams. Research shows that PCMHs improve quality and the patient experience, and increase staff satisfaction—while reducing health care costs. Practices that pursue the PCMH model of care have made a commitment to continuous quality improvement and a patient-centered approach to care.
This concept offers continuity of care by communicating its roles and responsibilities to patients/families/caregivers. Staff are organized and trained to work at the top of their license. Staff work as a team to deliver patient-centered care. The National Academy of Medicine defines team-based care as “…the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient – to accomplish shared goals within and across settings to achieve coordinated, high-quality care.”
This concept documents and analyzes patient and community information. The information is used to provide evidence-based care that supports population health needs and the delivery of culturally and linguistically appropriate services. This pillar of patient-centered care recognizes social determinants of health and their impact on patients and communities.
This concept provides accessible and continuous care to patients. Patients/families/caregivers are able to access: services more quickly, “after hours” care, 24/7 clinical advice, and their personal health records. The practice considers the needs and preferences of the patient population when establishing and updating access policies.
This concept identifies patient needs at the individual and population levels to effectively plan, manage and coordinate patient care in partnership with patients/families/caregivers. Care management activities can include patient education, medication management and adherence supports, population management, risk stratification, care planning, and coordination of care transitions.
This concept works to coordinate care across the broader health care system, including specialty care, hospitals, home health care, community services and supports. Care coordination ensures communication with specialists and other providers in the medical neighborhood. The practice systematically tracks tests, referrals and care transitions to provide high quality care coordination.
This concept demonstrates a commitment to data-driven performance improvement regarding clinical quality, efficiency and patient experience, and engages staff and patients/families/caregivers in quality improvement activities. Activities include using evidence-based approaches to guide shared decision making with patients/families/caregivers, measuring and answering to patient experiences and patient satisfaction, implementing performance measurement and improvement, and performing population health management.