July 19, 2024

Patient-Centered Medical Home

What is a Patient-Centered Medical Home (PCMH)?

The patient-centered medical home (PCMH) is a model of care in which patients are engaged in a direct relationship with a chosen provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the comprehensive integrated care provided to the patient, and advocates and arranges appropriate care with other qualified providers and community resources as needed.

PCMH practices develop transdisciplinary care teams to improve care coordination and care management of patient populations aiming to improve safety, efficiency and quality in patient care. By becoming a recognized PCMH, practices can improve care delivery and take advantage of private or public incentive payments that reward patient-centered medical homes. The Patient Protection and Affordable Care Act (ACA) offers enhanced federal funding to states for health homes serving Medicaid beneficiaries. Provider groups and healthcare organizations can visit their federal and state government and private insurers’ websites for information on funding and reimbursement initiatives.

Delivery system reform and the potential for shared savings available through programs promoted by the Center for Medicare & Medicaid Innovation (The Comprehensive Primary Care initiative, The Advanced Primary Care Practice Demonstration and the Advance Payment ACO Model) hold promise to further expand access to PCMHs for patients, specifically elderly, chronically ill and low income populations across the country. Because the PCMH is foundational to Accountable Care Organizations (ACOs) also known as “medical neighborhoods,” the PCMH is likely to gain greater prominence as ACOs continue to develop in the marketplace.

There are several steps necessary to begin the PCMH recognition and/or accreditation process. To start, review the mission and vision of your practice organization.  Develop a working definition of Patient Centered Care.  Begin to develop, review and update documentation of your practice policies and procedures and do a thorough analysis of your operational workflows.

The following resource tools and manuals will support your organization’s journey toward developing a patient-centered medical home. Use the quick links below to jump directly to the information you want.

This resource list was prepared by Anna Gard, FNP-BC, of ACU in partnership with the National Health Care for the Homeless Council under a cooperative agreement.

PCMH Resources

The Safety Net Medical Home Initiative

The focus of this initiative is to develop a replicable and sustainable implementation model for medical home transformation in safety net practices. Listed are links to key articles, tools, and resources on patient-centered care, medical home and quality improvement topics. Register for the Medical Home Digest, a quarterly newsletter on updated issues and tools specific to the safety net populations. The November 2012 issue is devoted to vulnerable populations.

Paying for the Medical Home: Payment Models to Support Patient-Centered Medical Home Transformation in the Safety Net (PDF).  Safety Net Medical Home Initiative. Bailit M, Phillips K, Long A.  Bailit Health Purchasing and Qualis Health, Seattle, WA: October 2010. This publication provides an introduction to a series of policy briefs focused on payment reform opportunities to support and sustain the medical home.

Patient Centered Primary Care Collaborative PCMH Resources

The Patient Centered Medical Home Purchaser Guide developed by the Patient Centered Primary Care Collaborative (PCPCC) provides insightful overviews of the patient centered medical home including supplemental resources such as detailed case studies, descriptions of pilot programs, and a draft request for information (RFI) and contract language for employers/purchasers to use with their health plans.

Transforming Patient Engagement: Health IT in the Patient Centered Medical Home

A compendium of 15 articles and 23 case examples and tools for providers across the healthcare continuum to engage patients in their own care. This comprehensive resource was compiled by the Patient Engagement Task force of the PCPCC’s Center for eHealth Information Adoption and Exchange, and includes articles for a range of stakeholders—primary care providers, patients, caregivers, health IT developers, policy makers, employers and the broad spectrum of clinical team members who serve patients every day

 Healing Hands Vol. 16 No. 2 Spring 2012 (PDF)

This Health Care for the Homeless Clinicians Network Newsletter summarizes PCMH in the homeless setting and highlights best practices that are PCMH recognized.

Medical Home State Data Pages

The Data Resource Center, funded by the Maternal and Child Health Bureau, has partnered with the American Academy of Pediatrics to help state and family leaders quickly access data on how children and youth in each state experience care within a medical home. Measurement resources are available by state, practice, and policy.

State Implementation of Medical Home & Patient-Centered Care

The National Academy for State and Health Policy (NASHP) has a database of information on all 50 states policies and programs regarding medical home implementation. This site provides an interactive map with detailed information on each state’s current laws, partnerships, methods of defining a medical home, financing structure, and measurement of quality improvement. Resources include strategies for state implementation, archived webinars, and publications provide in-depth analysis of state-level policy on medical home implementation.

Closing the Quality Gap: Revisiting the State of the Science

(Vol. 2: The Patient-Centered Medical Home). Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Jul. (Evidence Reports/Technology Assessments, No. 208.2.) This report includes reviews of effectiveness of bundled payment programs, effectiveness of the patient-centered medical home, QI strategies to address health disparities, effectiveness of medication adherence interventions, effectiveness of public reporting, prevention of healthcare-associated infections, QI measurement of outcomes for people with disabilities, and health care and palliative care for patients with advanced and serious illness. The overview describes the scope of the eight reports; summarizing the quality levers, populations, interventions, outcomes, and other features across the reports; and discusses key messages by audience.

PCMH Practice Assessment Tools

PCDC’s Online Medical Home Solutions for Safety Net Providers
Offers an overview of the tenets of the NCQA PCMH 2011 Recognition Program, and focuses on individual NCQA PCMH standards. Through a practice assessment and interactive lessons, users determine a roadmap for transformation or formal recognition. The online training program then offers field-tested strategies to guide users through PCMH transformation or recognition, addressing key topics such as team selection and communication with stakeholders.?This course is designed for all levels of staff at practices who either want to obtain NCQA PCMH 2011 Recognition and/or for practices looking to transform into a medical home without formal recognition.

PCMH Recognition & Accreditation Programs

The HRSA PCMH Initiative encourages its grantees (330H) to apply for NCQA recognition and will cover the costs for the NCQA survey tools and recognition fees.  HRSA will provide a PCMH training/mentoring program. Organizations interested in HRSA support for initial NCQA PCMH recognition under the PCMHH Initiative must complete a Notice of Intent.

National Center for Medical Homes Implementation

Developed by the American Academy of Pediatrics, this website provides contacts for organizations that have developed or in the process of developing programs that recognize and/or accredit various health care organizations as medical homes according to specified sets of standards.

National Committee for Quality Assurance (NCQA)

NCQA is currently the most widely adopted evaluation model with 16,000 clinical sites recognized and currently expanding to military and FQHC clinics.  The most recent 2011 standards emphasize behavioral health inclusion and incorporate Meaningful Use of EHRs, stages 1 and 2.  The timeframe for recognition approval 30-60 days and 5% of clinical practice sites will be audited.

NCQA Patient-Centered Medical Home Survey Tool

This web-based publication includes the Standards and Guidelines (the requirements to meet the Standards as well as explanations and examples.) The Survey Tool also includes all the information and the electronic data collection tool needed to prepare and submit materials to apply for recognition.

Joint Commission Primary Care Home Initiative

The Joint Commission has expanded the process of accrediting ambulatory health care organizations to those who are also interested in electing the Primary Care Home option. This initiative complements the Ambulatory Care Accreditation Program and is consistent with the new health care reform efforts to improve the coordination, quality and efficiency of health care services. This initiative is designed to combine the improvements in quality of care and patient safety achieved through accreditation with increased reimbursement from third party payers when the additional requirements of a Primary Care Home are met.

Accreditation Association for Ambulatory Health Care (AAAHC)

The Accreditation Association for Ambulatory Health Care is a private, non-profit organization that develops standards to advance and promote patient safety, quality and value for ambulatory health care through peer-based accreditation processes, education and research. The AAAHC Medical Home On-site Certification Handbook provides specific standards for the Medical Home.