Improving patient satisfaction, quality of care and improving the outcomes of individuals and populations while reducing costs are the goals of the medical home model. Although an agreement on an exact definition of a medical home remains elusive, the basic elements that create the framework of a Patient Centered Medical Home (PCMH) are:

  • Individualized, continuous care from a personal provider
  • Coordinated and integrated care across settings
  • ŸA multidisciplinary team approach to whole person care
  • Patient empowerment and self management
  • 24/7 access to the care team 
  • ŸClinical information technology systems

Defining the PCMH

Most medical groups utilize a multidisciplinary team of individuals, each of whom accept responsibility for the care and service provided to patients in primary care practice. PCMH emphasizes teamwork and whole person care, with a focus on the type of care a patient needs, when it is needed and in a manner that is appropriate for that patient.

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Utilization of an electronic health platform allows for effective communication between team members and patients, accurate up-to-date documentation, and efficient access to medical records and clinical decision support tools.

Coordinated Care

The PCMH team members include the patients, family, physicians, specialty providers, registered nurses, nurse practitioners, physician assistants, a hospitalist coordinator, certified medical assistants, practice supervisors, and patient service representatives. Clinical and non-clinical job functions are performed by the team to ensure that the care and service each patient receives is timely and appropriate for that patient.

The primary care provider develops relationships with patients building the foundation for patient-centered, continuous, comprehensive care and leads the care team. They are responsible for coordinating patient care. Providers proactively evaluate patients by risk stratification to prioritize patient needs and efficiently utilize the skills of the team in providing care. For example, when a patient is identified to have complex needs, nursing will provide additional education, facilitate appointments with specialists and follow up to ensure that any ordered reports are received for provider and patient discussion.

The registered nurse collaborates with the provider, communicates with the patient and other care team disciplines. Health promotion, identification of community resources, education of disease processes, and disease prevention are emphasized. Monthly health awareness promotions brings attention to the importance of preventative cancer screenings, immunizations, and chronic disease self management.

The hospitalist program coordinator contacts patients at the time of discharge and electronically notifies the care team in the office. The RN may then contact the patient if needed prior to their scheduled follow up appointment, to educate and monitor in order reduce the gaps in care. Coordination of care in transitions from hospital to home is critical in reducing hospital readmissions.