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Table of Contents

Magill’s Medical Guide, 9th Edition

Patient-centered medical home

by Muneeza Khan, , MD, FAAFP

Category: Health care system

Also known as: Medical home, health care home

Anatomy or system affected: Biopsychosocial

Specialties and related fields: Pediatrics, family and geriatric medicine, home health, evidence-based practice

Definition: A team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal health care outcomes.

The patient-centered medical home (PCMH) is a care model designed to enhance the care delivered to patients while still allowing attention to each individual’s unique needs. The process of implementing a PCMH improves the quality, efficiency and effectiveness of care.

In a 2007 document entitled Joint Principles of the Patient-centered Medical Home, the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics and the American Osteopathic Association defined the model to include patient access to a personal physician who leads the care team; a care team designed to provide comprehensive care at all stages of life from birth to end-of-life care; integrated and coordinated care that takes into consideration the patients ethnicity and culture; use of evidence-based medicine to enhance patient outcomes; and, a commitment to access to care. The care team includes physicians, physician assistants, advanced practice nurses, social workers, nutritionists and others who interact with the patient to meet their total care needs. Smaller practices may link with others to deliver the comprehensive care needed.

As health care in the United States moves away from payment for numbers of patients treated to a payment system based on quality and outcomes of care, the need for change in the delivery system is evident. Patients and payers increasingly expect health outcomes are quality driven. Personalized care that is coordinated between specialists, especially with chronic diseases such as diabetes and heart disease, is critical. As payments are stretched, improved access to appropriate care rather than excessive care must become the norm. Physicians are experiencing stress from patients and payers for care that may or may not be reimbursed. Physicians want to deliver the best quality of care possible in a safe and effective manner, while remaining financially solvent.

The PCMH model enables a physician practice to be ready for changes in reimbursement structures such as merit-based incentive payments (MIPs), alternative payment models (APMs), and accountable care organizations (ACO). The MIPS provides additional payment based on evidence-based and practice-specific quality measures reported to the payer. The APM provides incentive payments for specific conditions, care episodes or a population for high quality and cost-efficient care. An ACO is a group of doctors, hospitals, and other health care providers, who work as a team to provide coordinated, high-quality care to Medicare patients. As practices transition to PCMH models, cost savings and more efficient use of resources results. More primary and multispecialty physician practices are developing a PCMH model in their practices as resources are stretched.

More recently, single specialty clinics, such as medical oncology practices, are developing PCMH models designed to coordinate the care cancer patients need from initial diagnosis to cure or end-of-life care. As the model becomes more accepted, other single disease specialties may attempt to adapt the model to their practice patterns.

BACKGROUND

The PCMH is widely accepted as a model of excellence in primary care delivery. While the word home is used in the title, it is not a place but rather a way of organizing a care partnership between the physician and the patient. Working together with the care team, the patient develops a personalized care plan that addresses physical, mental, and supportive care needs. Care is considered to be 24/7; the patient has access to a provider round the clock. Medicine reconciliation, or reviewing all the medicines the patient is taking, is an important part of participation in a PCMH. Too often, patients see multiple doctors for a variety of conditions and may receive prescriptions that interact inappropriately causing more damage than good. Encouraging wellness by supporting appropriate health behaviors such as stop smoking and weight loss is also a part of this model of care.

The PCMH is comprised of five components. Comprehensive care means meeting most of a patient’s physical and mental needs, including prevention, screening, acute and chronic treatment to end-of-life care. Patient-centered care focuses on the needs of the whole patient with emphasis on establishing a long-term relationship with both patients and caregivers over time.

A significant complaint about the US health system is that the care provided is often fragmented as multiple specialists provide care, often with little communication with other providers. Coordinated care is important to deliver optimal outcomes. Preventing multiple drug interactions, choosing noninvasive care over surgery, and managing side effects of multiple diseases are just a few reasons that coordinated care is needed.

Providing access to health care is a critical component of a healthy population. Access to care is often dependent on the type of private or government payments available. Patients without insurance are often severely limited in the care they receive or may even be denied care. Self-pay is not a realistic option as the cost of health care continues to rise dramatically. Insurance and government payers negotiate reduced rates for care, but self-pay patients are often expected to pay full price for care delivered.

Quality of care is important to the delivery of appropriate and safe outcomes. A PCMH is committed to the use of evidence-based medicine and clinical practice guidelines. Clinical practice guidelines are often developed by consensus panels of subject experts based on extensively researched evidence and are considered to be the optimal care that needs to be delivered to a patient. Shared decision-making with the patient, caregivers and other physicians involved in ongoing care enhances care delivery, safety and provides the most optimal outcome of treatment.

The US health care system is in dire need of overhaul to control costs and increase access to all citizens. Increasing access to appropriate care is critical. Care coordination is one method to better manage the patient population seeking care. The PCMH is one model that shows great promise going forward.

IMPLEMENTATION

The PCMH is generally considered to be based in the primary care practice and focuses on how health care is organized and delivered by putting the patient at the center. The five components necessary to develop the model are comprehensiveness, patient-centered, coordinated care between providers, providing patient access to care and quality and safety. A smaller practice may need to partner with others to develop a PCMH. Supportive functions necessary include a robust information technology system, a workforce with the attributes and attitude to put patients first, and financial stability as the system is implemented. Professional organizations and the Agency for Healthcare Research and Quality all have resources that can assist a physician practice to determine their readiness to develop a PCMH as do agencies that provide assessment and recognition programs.

Becoming recognized as a PCMH may enhance payment from providers by as much as a 10 percent payment increase. Recognition programs include a variety of agencies in different regions of the United States. The Joint Commission Primary Care Medical Home Recognition Program, the Accreditation Association for Ambulatory Health Care Medical Home Program and the URAC Patient-Centered Medical Home Recognition Program are just a few examples. The National Committee for Quality Assurance (NCQA) has a PCMH evaluation program that currently recognizes over 12,000 practices as meeting their standards. There are also more than 100 payers who support the NCQA recognition program with financial incentives. Reviewing the standards from these agencies will also assist in the steps needed to become a PCMH.

PERSPECTIVE AND PROSPECTS

The PCMH will continue to be an integral component of health care going forward. As both patients and payers demand more for their dollar, coordinating care that is appropriate, comprehensive, of high quality and safe will be important. The PCMH helps deliver this level of patient-centered care. Per the NCQA, the number of PCMH programs is increasing. Barriers to ensuring a thriving PCMH include financial constraints, lack of technological support and infrastructure. It is important to maintain the focus on patient-centeredness while defining how a PCMH can optimally serve the needs of a varied patient population. Practices will have to innovate and evolve in order to meet the unique needs of the patients they serve as they advance into the future of health care.

For Further Information:

1 

“Accountable Care Organizations.” Centers for Medicaid and Medicare Services, www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/index.html.

2 

“Alternative Payment Model Overview (APM).” Centers for Medicaid and Medicare Services, qpp.cms.gov/apms/overview.

3 

American Academy of Family Physicians, American College of Physicians, American Academy of Pediatrics, American Osteopathic Association. “Joint Principles of the Patient-Centered Medical Home.” American Academy of Family Physicians, www.aafp.org/practice-management/transformation/pcmh. html.

4 

Appold, Karen. “Patient-Centered Medical Homes: Were They Built to Last?” Managed Healthcare Executive, vol. 31, no. 5, May 2021.

5 

“Defining the Medical Home: A Patient-centered Philosophy That Drives Primary Care Excellence.” Patient-Centered Primary Care Collaborative, www.pcpcc.org/about/medical-home.

6 

“The Merit Based Incentive Payment System (MIPS).” Centers for Medicaid and Medicare Services, www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessm ent-Instruments/Value-Based-Programs/MACRA-MIPS-an d-APMs/Quality-Payment-Program-MIPS-NPRM-Slides.pd f.

7 

“Patient-centered Medical Home Recognition.” National Committee for Quality Assurance, www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh.

8 

“Transforming the Organization and Delivery of Primary Care.” Agency for Healthcare Research and Quality, www.ahrq.gov/ncepcr/tools/pcmh/index.html.

9 

US Department of Health and Human Resources. “Defining the PCMH.” Patient-centered Medical Homes. Agency for Healthcare Research and Quality,pcmh.ahrq.gov/page/defining-pcmh.

Citation Types

Type
Format
MLA 9th
Khan, Muneeza. "Patient-centered Medical Home." Magill’s Medical Guide, 9th Edition, edited by Anubhav Agarwal,, Salem Press, 2022. Salem Online, online.salempress.com/articleDetails.do?articleName=MMG2022_1033.
APA 7th
Khan, M. (2022). Patient-centered medical home. In A. Agarwal, (Ed.), Magill’s Medical Guide, 9th Edition. Salem Press. online.salempress.com.
CMOS 17th
Khan, Muneeza. "Patient-centered Medical Home." Edited by Anubhav Agarwal,. Magill’s Medical Guide, 9th Edition. Hackensack: Salem Press, 2022. Accessed September 16, 2025. online.salempress.com.