The patient-centered medical home (PCMH) is a model of health care delivery that is based on an ongoing personal relationship with a physician. This personal patient/physician relationship provides continuous and comprehensive health care.
A medical practice that operates as a PCMH consists of the personal physician leading a team of health care professionals who collectively take responsibility for the ongoing care of the patient.
A whole person orientation is a key component of the PCMH. The personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for managing care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end-of-life care.
Care is coordinated across all elements of the patient’s community including the health care system (hospitals, home health agencies, nursing homes, consultants and other components of the complex health care system), facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it.
Quality and safety are hallmarks of the patient-centered medical home. Physician practices that adopt the PCMH model become advocates for their patients to support the attainment of the best health outcomes. These outcomes are defined by a care planning process driven by a compassionate and robust partnership between the patient, the patient’s primary physician, other physicians, health care providers and family members. The patient actively participates in decision-making and provides feedback to ensure expectations are being met.
Evidence-based medicine and clinical decision-support tools guide decision making. Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement. Information technology supports optimal patient care, performance measurement, patient education, and enhanced communication.
This enhanced access to health care means the practice provides patients with options such as open scheduling, expanded hours and various arrangements for communication between patients, the physician, the practice team and office staff.
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