Patient-Centered Medical Home Model

The patient-centered medical home (PCMH), as defined by the U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) and the Patient-Centered Primary Care Collaborative, is a model for providing patient care that is comprehensive, patient-centered, coordinated, accessible, and high quality. The PCMH is a provider-based model for care coordination that can be implemented within a primary care practice.

In 2007, the Joint Principles of the Patient-Centered Medical Home were released by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association.

Characteristics of the PCMH model include:

  • A strong relationship between every patient and a primary care physician
  • Coordination between the physician and the practice’s team of clinicians
  • Coordination of the patient’s care across various healthcare settings
  • The use of health information technology and analytical tools to facilitate care coordination

The Agency for Healthcare Research and Quality’s PCMH Resource Center provides evidence-based resources about the medical home and its potential to transform primary care and improve the quality, safety, efficiency, and effectiveness of U.S. healthcare.

In this model:

Resources to Learn More

AHRQ Patient Centered Medical Home Resource Center
Website
AHRQ posts links to reports and white papers explaining different aspects of the PCMH model and implementation. Resources are targeted to researchers, evaluators, and providers.
Organization(s): Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services

Behavioral Health Homes for People With Mental Health & Substance Use Conditions: The Core Clinical Features
Toolkit
This document describes the medical home model developed by the SAMHSA-HRSA Center for Integrated Health Solutions, focusing on integrating mental health and primary care providers.
Organization(s): SAMHSA-HRSA Center for Integrated Health Solutions
Date: 5/2012

Building Your Medical Home Toolkit
Toolkit
The toolkit supports your development and/or improvement of a pediatric medical home.
Organization(s): American Academy of Pediatrics

Care Transitions for Patients Experiencing Homelessness
Webinar
This webinar provides an introduction to transitional care and highlight a new care transition model developed by Oregon Health and Sciences University that targets low-income and uninsured patients, including those who are experiencing homelessness.
Organization(s): National Health Care for the Homeless Council
Date: 10/2012

Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act
Brief Report
This document gives an overview of the patient-centered medical home provisions in the Affordable Care Act, financing mechanisms, and implementation considerations for community health centers.
Organization(s): Safety Net Medical Home Initiative
Date: 10/2010

Improve Processes & Workflows
Toolkit
This site provides links to tools for practices to improve their workflows to support care coordination and patient-centered medical homes.
Organization(s): MMC Physician Hospital Organization

Improve Team Communication
Website
This site provides links to tools for practices to improve communication to support care coordination and patient-centered medical homes.
Organization(s): MMC Physician Hospital Organization

NASHP Medical Home & Patient-Centered Care
Website
Targeted to providers interested in implementing a PCMH model, this website explains key PCMH characteristics and provides descriptions of the strategies states are taking to implement PCMHs, as well as other PCMH-related strategies.
Organization(s): National Academy for State Health Policy

The Patient-Centered Medical Home
Website
This website from the American Academy of Family Physicians provides step-by-step project plans and tools to build a patient-centered medical home. It also includes a checklist for practices to determine if they are already a patient-centered medical home.
Organization(s): American Academy of Family Physicians

Patient-Centered Medical Home
Website
This website provides resources on NCQA’s patient-centered medical home model for providers interested in becoming a patient-centered medical home.
Organization(s): National Committee for Quality Assurance

Patient-Centered Primary Care Collaborative Webinars
Website
Webinars produced by the Patient-Centered Primary Care Collaborative on a range of patient-centered medical home-related topics.
Organization(s): Patient-Centered Primary Care Collaborative

Person-Centered Healthcare Homes
Report
This website offers providers a range of resources to help them become patient-centered medical homes, with an emphasis on integrating mental health and primary care, and behavioral home certification.
Organization(s): SAMHSA-HRSA Center for Integrated Health Solutions
Date: 2009

Primary Care For all
Webinars
A series of webinars on patient-centered medical home and care coordination topics.
Organization(s): Primary Care For all

The Safety Net Medical Home Initiative: Patient-Centered Care for the Safety-Net System
Toolkit
This website provides implementation guides for providers interested in becoming patient-centered medical homes.
Organization(s): The Commonwealth Fund
Date: 4/2012

Safety Net Medical Home Initiative Resources & Tools
Website
This website is a collection of resources to help practices implement a patient-centered medical home model.
Organization(s): Safety Net Medical Home Initiative