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Understanding the Patient-Centered Medical Home

November 3, 2010

If you are a medical practice manager and thinking about making your practice a Patient-Centered Medical Home or getting involved in a PCMH, first find out from leading organizations what this approach requires.

The Patient-Centered Medical Home is a team-based model that provides continuous and coordinated care throughout a patient’s lifetime.

The American Academy of Pediatrics introduced the PCMH concept in 1967 to refer to a central location for archiving a child’s medical records. In 2002, the AAP tweaked the idea to include operational characteristics that qualify a PCMH as accessible, continuous, comprehensive, family-centered, coordinated, compassionate and culturally effective.

The AAP, the American Academy of Family Physicians, the American College of Physicians and the American Osteopathic Association have jointly compiled a list of principles that describe the characteristics of the Patient-Centered Medical Home.

Each patient has an ongoing relationship with a personal physician and the personal physician leads a team of individuals at the practice who are collectively responsible for ongoing patient care.

The personal physician is responsible for providing care that spans all stages of life, such as acute care, chronic care and preventive services and end-of-life care. They are also responsible for for arranging care with other qualified professionals when needed.

Care is coordinated through all elements of the healthcare system, such as sub-speciality care, hospitals, home health agencies and nursing homes, as well as through a patient’s community, family, and public and private community-based services. Through registries, information technology, health information exchange and other means, patients will get the exact care they need where they need it. The care will also be administered in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the PCMH. This is achieved by advocating for patients to attain optimal outcomes, providing evidence-based medicine and clinical decision support to help with decision-making and allowing patients and families to participate in quality improvement activities at the practice level.

Open scheduling, expanded hours and new options for communication between patients, their personal physicians and practice staff allow for extended care options.

Payment should appropriately recognize the added value provided to patients in a PCMH. Some examples include paying for services associated with coordination of care both within the practice and between consultants, paying for care that falls outside of the face-to-face visit, and supporting the adoption and use of health information technology for quality improvement. 

If making your practice a PCMH interests you, visit or log on to for more information.

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