Written By Guest Bloggers Robert Marshall, MD, MPH, MISM, CMO, HIT GROUP and Nicholas Appolonia, FA-C, MSN, PhD, CMIO, CEO, HIT GROUP

Medical care delivered to the patient can be provided in a hospital setting or within the community. In the United States, primary care health care in the community is ideally achieved through what is known as a patient-centered medical home (PCMH). This is in fact a model of health care delivery to those patients who tend to utilize healthcare facilities often.  In addition, these facilities are monitored internally and in some cases externally for quality patient care, health optimization, outcomes and overall customer service delivery.  All of which are measured by performance metrics with use of collaborative tools and other mechanisms such as National Committee for Quality Assurance (NCQA).

In this article, we shall take a look at the different aspects of patient-centered medical homes, discuss what exactly the model involves and how it can benefit patients.

Defining Patient-Centered Medical Homes (PCMH)


The 2007 Joint Principles of the Patient-Centered Medical Home – as developed by the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics and the American Osteopathic Association – are as follows:

  • Personal physician – Every patient has their personal physician as their first port of contact
  • Physician-led practice: Patients have access to a personal physician who leads the care team within a medical practice.
  • Whole-person orientation: The care team provides comprehensive care, including acute care, chronic care, preventive services, and end-of-life care, at all stages of life.
  • Integrated and coordinated care: Practices take steps to ensure that patients receive the care and services they need from the medical neighborhood, in a culturally and linguistically appropriate manner. A number of factors such as health information exchanges and information technology play a role in this
  • Focus on quality and safety: Practices use the quality improvement process and evidence-based medicine to continually improve patient outcomes.
  • Enhanced Access: Practices commit to enhancing patients’ access to care. This would mean that patient-centered medical homes would require to remain open for longer hours and that need to be more ways to contact a healthcare professional within the medical home out of hours. Patient portals, secure patient-provider communication and telemedicine can play important roles here.
  • Payment Reform – Patients must feel that they are getting more value from a patient-centered medical home than if they just paid a standard fee for the visit/consultation. Different fee structures are integral to offering an effective patient-centered medical home model.

While the patient-centered medical home model was started and originally defined by the four organizations listed above, a number of different medical groups, such as the American College of Obstetrics and Gynecology, the American College of Cardiology and the American College of Chest Physicians, have now endorsed the principles of the PCMH. Having non-primary care specialties on board with the PCMH principles is critical to the overall success of the PCMH, because this is what creates the PCMH Neighborhood and lays the foundation for the Accountable Care Organization.

Core attributes of patient-centered medical homes

Below are some of the fundamental attributes of PCMH.

  1. First contact access – This involves offering access to patients to various health care services through distant contact or through face-to-face contact with the healthcare professionals within the service.
  2. Comprehensiveness – The patient-centered medical home model is based around providing patients holistic medical care that covers various aspects of their health. This can include managing various underlying co-morbid conditions, mental health illnesses and even long-term chronic illnesses.
  3. Coordination – This refers to coordinating various activities amongst different healthcare providers within the model to ensure accurate care is provided.
  4. Integration of care -This involves prioritization of various services that need to be delivered during active illnesses in addition to optimizing treatments when it comes to prevention and mental health issues. In addition, the model of patient-centered medical homes is to join together services that can be provided in the community with those that are provided in the hospital or by other specialists.
  5. Sustained partnership – This refers to building a good relationship with the patient; one that is based around confidence and trust.

New aspects

In the recent years, the model for patient-centered medical homes has changed. While its core beliefs remain the same, the approach that is being adopted is different.

For example, new ways have emerged to organize a clinical practice to ensure that it meets the needs of the patient. Services such as disease registries, team-based management and same-day appointments are some of the innovations that have been adopted. The ultimate aim is to ensure that every patient gets standardized, appropriate access care of high quality.

Unfortunately, it does not appear that every primary care practice is prepared to become a patient- centered medical home. This is because the transformation requires considerable change that includes altering infrastructure, changing management and developing leadership. If a practice does decide to become a patient-centered medical home, it must be prepared for a series of ups and downs before it can sustain a plateau.

Future directions for the PCMH and Primary Care

In a report from the Patient-Centered Primary Care Collaborative (PCPCC), published in January 2015, a number of respected experts in the primary care and PCMH fields felt that the following were key areas for the future of both primary care and the PCMH model:

  • Integrating services both inside and outside primary care practices. Examples include integrating behavioral and oral health into PCMHs and integrating PCMHs into Accountable Care Organizations (ACO) and various community based organizations and services;
  • Providing financial support for enhanced primary care that helps control the total cost of care while maintaining or improving quality for patients;
  • Developing the primary care health professions workforce to embrace all members of the team, including the patient and their family/caregiver;
  • Engaging patients, consumers, and the public particularly in PCMH transformation and quality improvement activity; and
  • Embracing the potential of technology to support this model of care

Benefits of patient-centered medical homes

The primary benefit of patient-centered medical homes is to offer the patient is a comprehensive healthcare approach in a primary setting. It not only involves the relationship that the healthcare professionals have the patient, but also the links that the healthcare teams build with the patient’s family members and the remaining community.

The evidence supports the model. The same 2015 report from the PCPCC looked at the peer-reviewed medical literature, state government program evaluations and industry reports. They found 28 studies on the PCMH model and its effect on cost and care quality. This is what those studies reported:

  • 17 found improvements in costs
  • 24 found improvements in utilization of resources
  • 11 found improvements in quality
  • 10 found improvements in access
  • 8 found improvements in satisfaction


Patient-centered medical home is a concept that has been around for some time. It is based around certain principles and is built on a foundation of core attributes. The ultimate goal is to provide patients with the best quality, safest and most holistic care possible.


Stange, K. C., Nutting, P. A., Miller, W. L., Jaén, C. R., & Gill, J. M. (2010). Defining and measuring the patient-centered medical home. Journal of General Internal Medicine, 25(6), 601-612.

Nielsen, M., Gibson, A., Buelt, L., Grundy, P., & Grumbach, K. The patient-centered medical home’s impact on cost and quality. Annual review of the evidence 2013-2014. Patient-Centered Primary Care Collaborative. Milbank memorial Fund. January 2015.

American Academy of Family Physicians. The patient-centered medical home (PCMH). Practice Management. 2015. Available at: http://www.aafp.org/practicemanagement/