Patient Centered Medical Home

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The Patient Centered Medical Home (PCMH) is a model of primary care intended to hold significant promise for better health care quality, improved involvement of patients in their own care, and reduced avoidable costs over time. The model replaces episodic care based on illnesses and patient complaints with coordinated care and a long-term physician/patient relationship. Health information technology plays a crucial role in this model.

PCMH History

Although the term PCMH has been popularized in the last few years, the concept was first introduced by the American Academy of Pediatrics in 1967, initially referring to a central location for maintaining a child’s medical record. In 2007, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, and the American Osteopathic Association developed the joint principles of the PCMH. See also the Medical home

Joint Principles of a PCMH

Personal physician- Each patient has an ongoing relationship with a personal physician who provides comprehensive care.

Physician directed medical practice- The physician leads a team of health care workers who collectively manage patients

Whole person orientation- The physician takes responsibility for all of a patient’s health care needs, managing acute care, chronic care and preventive services.

Care coordination- Care is coordinated across health care settings (subscpecialty care, hospitals, home health agencies, nursing homes). This is facilitated by health information technology.

Quality and safety are emphasized throughout the patient’s care.

Access is enhanced through open scheduling, expanded hours and alternative communication methods.

Payment recognizes the added value provided to patients who have a PCMH.

National Committee for Quality Assurance Recognition

The most widely accepted set of standards for PCMH recognition has been developed by the National Committee for Quality Assurance (NCQA). Obtaining NCQA PCMH recognition requires completing an application and providing evidence that specific processes and policies are in place. Recognition is offered at three levels, with level 3 being the most advanced level. Recognition positions practices to take advantage of financial incentives offered by PCMH demonstration or pilot projects. These projects are offered by multi-payer initiatives, private insurers, Medicaid/CHIP and federal efforts (Medicare, Veterans Administration, Department of Defense). To apply for NCQA PCMH recognition, practices must conduct a self-assesment of their capability to meet each of the PCMH standards. Practices must then complete the online NCQA survey, which requires responses to questions, completion of worksheets and surveys, and attachment of supporting documentation (written protocols, screenshots, performance reports, survey results). All of these documents are uploaded and submitted for scoring. NCQA evaluates all data and scores the practice. An application fee of $500/provider is required.

Evidence to support the PCMH

Preliminary results of PCMH pilots across the United States have demonstrated decreased rates of emergency room visits, decreased rates of hospitalizations, reduced costs and improved performance on preventive and chronic disease quality indicators. However, evaluations are ongoing, with some interventions indicating favorable results, a few unfavorable effects on costs, or inconclusive results due to insufficient sample size or uncertain statistical significance. Stronger evaluations are needed to substantiate and refine the model.

NCQA PCMH Standards

There are 6 PCMH standards, each of which include several elements on which a practice is scored, and a total of 100 points possible. There are 6 must-pass elements which must be achieved in order to earn PCMH recognition.

PCMH 1: Enhance access and continuity • Patients have access to culturally and linguistically appropriate routine/urgent care and clinical advice during and after office hours • The practice provides electronic access • Patients may select a clinician • The focus is on team-based care with trained staff

PCMH 2: Identify/manage patient populations • The practice collects demographic and clinical data for population management • The practice assesses and documents patient risk factors • The practice identifies patients for proactive and point-of-care reminders

PCMH 3: Plan/manage care • The practice identifies patients with specific conditions, including high-risk or complex care needs • Care management emphasizes: -Pre-visit planning -Assessing patient progress toward treatment goals -Addressing patient barriers to treatment goals • The practice reconciles patient medications • The practice uses e-prescribing

PCMH 4: Provide self-care support/community resources • The practice assesses patient/family self-management abilities • The practice works with patient/family to develop a self-care plan and provide tools and resources • Clinicians counsel patients on healthy behaviors • The practice assesses and provides or arranges for mental health/substance abuse treatment

PCMH 5: Track/coordinate care • The practice tracks, follows-up on and coordinates tests, referrals and care at other facilities (e.g., hospitals) • The practice follows up with discharged patients

PCMH 6: Measure/improve performance • The practice uses performance and patient experience data to continuously improve • The practice tracks utilization measures such as rates of hospitalizations and ER visits • The practice identifies vulnerable patient populations • The practice demonstrates improved performance

Health information technology and the PCMH

Health information technology plays a central role in successfully operationalizing and implementing the key features of the PCMH. Electronic health records, electronic disease registries, internet communication with patients, e-prescribing and information exchange are all crucial to a fully functioning PCMH. The 2011 updated PCMH standards have been aligned with the Centers for Medicare and Medicaid Services (CMS) Stage 1 meaningful use requirements. PCMH elements include electronic prescribing, use of drug formulary, drug-drug and drug allergy checks, maintainance of up-to-date problem and medication lists, recording of demographics information, recording of vital signs, recording of smoking status, reporting ambulatory quality measures and implementing clinical decision support rules.

Submitted by Cara Litvin


[American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, & American Osteopathic Association. Joint principles of the patient-centered medical home, 2007.[1] [AHRQ Patient Centered Medical Home Resource Center][2] [NCQA Patient-centered medical home][3]