Patient-Centered Medical Home Model

The patient-centered medical home (PCMH) is a provider-based model for care coordination that can be implemented within a primary care practice. The PCMH, as defined by the Agency for Healthcare Research and Quality (AHRQ) is a model for providing patient care that is comprehensive, patient-centered, coordinated, accessible, and high quality.

AHRQ identifies five key characteristics of the PCMH model:

• Comprehensive care delivered by a team of providers, helping to integrate multiple types of care in-person or virtually
• Patient-centered care, emphasizing strong relationships between the patient, their family, and their medical home practice
• Coordinated care across various settings, helping connect the patient to needed healthcare services and social or community-based supports
• Accessible services that reduce barriers to care, including extended hours or different ways to access members of the care team
• A commitment to quality and safety, such as collecting performance management data, acting on findings, and sharing information about improvement activities.

The National Committee for Quality Assurance (NCQA) has established a model for patient- PCMH recognition. Practices seeking to earn PCMH recognition must meet standards and guidelines set forth by NCQA. Information regarding the redesigned PCMH recognition process is available from NCQA. Other PCMH recognition and accreditation programs are available from:

• The Joint Commission
• Accreditation Association for Ambulatory Health Care (AAAHC)

Examples of PCMH Programs

• Community Care of North Carolina (CCNC) has implemented a PCMH model with support from the North Carolina Department of Health and Human Services and the North Carolina Division of Medical Assistance. CCNC helps 14 regional networks in North Carolina to implement care improvement initiatives for Medicaid. CCNC has extended care into rural communities by connecting providers and community organizations in North Carolina's 100 counties.
• Crete Area Medical Center (CAMC) Physicians' Clinic has implemented a PCMH model in Crete, Nebraska. The model has been successful at reducing hospitalizations and emergency department visits among patients with chronic conditions. One key facilitator for the program was early adoption of electronic health records, which staff use for multiple purposes, including diabetes education.
• The Atlantic General Hospital Patient Centered Medical Home is improving the quality of care while decreasing costs in rural Maryland and Delaware. The program uses a comprehensive mix of care coordination, remote patient monitoring, chronic disease management, and care transition support.

Implementation Considerations

Implementing the PCMH model requires a significant investment of time and resources. Challenges related to the implementation of a PCMH model may include:

• Shifting the culture of the practice from physician-centered care to team-based care
• Developing customized information systems, which may be costly and labor intensive
• Change fatigue, which can result in staff turnover
• Administrative burden

Strategies that have helped practices to successfully transition to the PCMH model include:

• Setting aside time for planning and reflection
• Improving communication procedures within the practice
• Cultivating meaningful relationships between physicians and other clinical staff
• Implementing a systematic change management process to guide the transition
• Developing a HIT implementation plan
• Working with software vendors to customize and improve HIT tools

Resources to Learn More

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

Patient-Centered Primary Care Collaborative Webinars
Website
A collection of webinars on a range of PCMH-related topics searchable by topic and year.
Organization(s): Patient-Centered Primary Care Collaborative