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The Patient-Centered Medical Home (PCMH): Building a Better Health Care Model. Objectives. Identify current priorities to enact health care reform. Describe the Patient-Centered Medical Home (PCMH) model of care.

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Identify current priorities to enact healthcare reform.

Describe the Patient-Centered Medical Home (PCMH) model of care.

Understand how the PCMH model is an appropriate method to address priority health reform issues.

Understand Family Medicine’s role in the development and adoption of the Patient-Centered Medical Home.

patients today are savvy consumers of health care and have higher expectations
Patients today are savvy consumers of health care and have higher expectations.
  • Communication
  • Access
  • Convenience
  • Coordination
  • Responsiveness
    • Source: Medfusion, an AAFP affinity partner, 2008
patient expectations
Patient Expectations
  • 75% want the ability to interact with their physician online (appointments, prescriptions, test results).
  • 77% want to ask questions without a visit.
  • 75% want email access as part of their overall care.
  • 62% of patients say access to these services would influence their choice of physicians.
    • Source: Medfusion, an AAFP affinity partner, 2008
family medicine is leading the way to make health care more patient centered
Family Medicine is leading the way to make health care more patient-centered.

“Will family medicine teachers prepare their students and residents to help practices transform and meet the infrastructure principles? I believe that we will, not simply because doing so will likely increase our financial situation but because building PCMH’s that meet the care and infrastructure principles will improve the care we provide to meet our patients’ and our communities’ needs. We will build our PCMH practices, because it is the right thing to do and it reflects our core values.”

John C. Rogers, MD, MPH, MEd


Society of Teachers of Family Medicine

Fam Med 2008;40(1):11-2.)

health care reform
Health Care Reform

Priorities for US health care reform…

Quality-WHO (World Health Organization) identifies the US health care system as the “most individually responsive”

  • WHO ranks US health care 37th overall (among 191 countries)


  • People with acute and chronic medical conditions receive only about two-thirds of the health care that they need.
  • Between 20 and 30% of tests and procedures provided to patients are neither needed nor beneficial.

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth Fund

*Schuster, McGlynn, and Brook.

health care reform1
Health Care Reform

Priorities for US health care reform…


  • The U.S. spends more on health care per capita than any other nation.
  • The U.S. spends more on health care as a proportion of GDP (Gross Domestic Product) than any other nation.


  • Public confidence in hospitals and personal doctors remains relatively high.
  • While individuals report generally positive experience with medical care, public confidence and trust in the system at large is eroding.

*Leatherman and McCarthy, Quality of Health Care in the United States: A Chartbook, 2002. The Commonwealth

health care reform2
Health Care Reform

Priorities for US health care reform…


  • Lack of insurance is a major reason for not obtaining access to needed care.
  • The 40 million Americans without insurance coverage are less likely to obtain needed medical care and preventive tests
  • Even with insurance, barriers to care still exist:
    • Lack of an established relationship with a doctor
    • Language and Cultural barriers
    • Social Determinants of Health
    • Transportation issues
    • Geography
    • High out-of-pockets costs even for those with insurance ie: high deductibles, underinsured, etc.
health care reform3
Health Care Reform

Priorities for US health care reform…


  • Infrastructure for health care delivery has not kept pace with the electronic innovations of other industries.
  • Many institutions still rely on systems that are not automated and allow opportunities for human error, even though technology exists to minimize errors and improve efficiency.
an effective and efficient health care system is a primary care based health care system
An effective and efficient health care system is a primary care-based health care system
    • Provides access to basic health care services
    • Manages health disparities
    • Coordinates care
    • Controls cost
    • Offers sustainability
brief history of the pcmh
Brief History Of The PCMH






innovative solution history of the pcmh concept
Innovative Solution:History of the PCMH Concept
  • Introduced by American Academy of Pediatrics (AAP) in 1967
  • Initially referred to a central location for medical records
  • The medical home concept was expanded in 2002 to include:
    • Accessible
    • Continuous
    • Comprehensive
    • Family-centered
    • Coordinated
    • Compassionate
    • Culturally sensitive care
  • In 2007, the AAP, the American Academy of Family Physicians (AAFP), the American Osteopathic Association (AOA), and the American College of Physicians (ACP) adopted a set of joint principles to describe a new level of primary care.
joint principles of the patient centered medical home
“Joint Principles” of the Patient-Centered Medical Home
  • A personal physician who coordinates all care for patients and leads the team.
  • Physician-directed medical practice – a coordinated team of professionals who work together to care for patients.
  • Whole person orientation – this approach is key to providing comprehensive care.
  • Coordinated care that incorporates all components of the complex health care system.
  • Quality and safety – medical practices voluntarily engage in quality improvement activities to ensure patient safety is always being met.
  • Enhanced access to care – such as through open-access scheduling and communication mechanisms.
  • Payment – a system of reimbursement reflective of the true value of coordinated care and innovation.
growing support for the patient centered medical home
Growing Support for the Patient- Centered Medical Home
  • Partnerships are developing as more and more stakeholders see value in the Joint Principles.
  • The Patient Centered Primary Care Collaborative (PCPCC)* is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and others to develop and advance PCMH.
  • The PCPCC has well over 1,000members. *

The Patient Centered Medical Home

The Family Medicine Model

Heath Information Technology


Health IT

Practice Organization

Patient Experience

Patient-centered Care



Family Medicine Foundation

Patient-centered | Physician-directed


Culture of Improvement

Medical Neighborhood

Risk-stratified Care Management

  • Establish baseline performance measures
  • Collect and analyze data
  • Discuss best practices and improvement
  • Conduct regular clinical team meetings
  • Understand ways to identify patient’s risk status
  • Plan out care for chronic conditions and preventive care
  • Identify “high-risk” patients
  • Use tools to track populations by risk category
  • Manage care transitions and build linkage to community resources
  • Coordinate care with specialists and outside facilities
  • Evaluate care transition process




Convenient Access

Shared Decision Making

Patient Experience

  • Same-day appointments and extended hours
  • E-mail communication with patients (E-visits)
  • Web portals for Rx refill and appointments
  • Translation and Culturally appropriate services
  • Understanding the patient’s social barriers, goals and priorities
  • Create care plans in collaboration with patient/caregiver
  • Monitor progress between visits
  • Conduct patient satisfaction surveys on a regular basis
  • Establish patient advisory panel and QI activities
  • Conduct patient focus groups






Financial Management

Culture of Change

Practice Environment

  • Lab testing
  • Prescriptions
  • Registries
  • All staff are aware of the most efficient ways to deliver care
  • National policies support the investment of resources into primary care practices that are effective and efficient
  • Establish a PCMH leadership team
  • Engage all members of the practice in a shared vision
  • Provide staff education and training to support patient-centered care
  • Staffing model supports team-base care
  • Define roles for team members
  • Include health coach and care coordination functions

Practice Organization

Patient-centered Care






Digitally Connected



EHR Reporting Tools

  • Patient reminders
  • Patient notification for

new information

  • Reminders for

recommended care or

health maintenance

  • Makes patient registries


  • Enhances care

coordination by

improving information

flow with other

physicians, practices,

and providers

  • Improves patient -

physician communication

  • Point-of-care learning , alerts and reminders
  • Clinical decision support

(e.g., Epocrates)

  • Can quickly pull clinical

data for quality analysis

  • Can enhance business


  • Population health management through patient registries




Practice Organization

Patient – centered Care



Family Medicine Foundation


Great Outcomes

  • Good for patients
    • Patients enjoy better health.
    • Patients share in health care decisions.
  • Good for physicians
    • Physicians focus on delivering excellent medical care.
  • Good for practices
    • Team works effectively together.
    • Resources support the delivery of excellent patient care.
  • Good for payors and employers
    • Ensures quality and efficiency.
    • Avoids unnecessary costs.

Great Outcomes




Practice Organization

Patient-centered Care

Quality Care

Family Medicine Foundation

does pcmh work
Does PCMH Work?
  • Fully implemented the PCMH hits the triple AIM, better health, better care, lower costs
  • Improves practice organization, work environment and job satisfaction
  • No longer a pilot…Now a program with proven results

the pcmh model in family medicine residency training
The PCMH Model in Family Medicine Residency Training
  • “Preparing the Personal Physician for Practice” (P4)
  • The P4 Initiative was designed to inspire and examine innovation in family medicine residency training.  
  • Sponsors are the American Board of Family Medicine, the Association of Family Medicine Residency Directors, and TransforMED.
  • Different approaches range from moving the continuity clinic into a new community setting, to expanding to a four-year program, to providing the opportunity for tracking and obtaining additional degrees while in training, and more. 
  • The aim of P4 is to spur innovation in all family medicine residencies to best prepare family physicians be the excellent personal physicians of tomorrow.
  • Initially, 84 Family Medicine residencies applied to participate in the P4 Initiative.
  • The 14 P4 residencies were selected as participants for more intensive evaluation of outcomes to determine what works best.

pcmh model and health care reform
PCMH Model and Health Care Reform
  • Attempts to fix part of the problem without addressing it comprehensively will not lead to viable solutions.
  • Advocacy by all stakeholders is necessary.
    • Community projects through local hospitals and resource networks
    • State projects for regional payors and state Medicaid programs
    • National support for changing how care is delivered and for ensuring a prepared workforce to deliver care
family physicians and the pcmh

Patient-centered Care

Family Physicians and the PCMH
  • PCMH is a place, not a person.
  • Patient-centered, Physician-directed.
  • Family physicians
    • Provide comprehensive care
    • Care for all patients
    • Coordinate care
    • Provide care that is effective

and efficient*

      • Future of Family Medicine
      • *Starfield data

Practice Organization




Quality Care

family physicians how we provide care
Family PhysiciansHow we provide care:
  • Acute injuries and illnesses
  • Health promotion and behavior change
  • Hospital care
  • Chronic disease management
  • Maternity care
  • Well-child care and child development
  • Primary mental health care
  • Supportive and end-of-life care
family physicians how we view patients
Family PhysiciansHow we view patients:
  • Consider all of the influences on a person’s health.
  • Know and understand people’s limitations, problems, and personal beliefs when deciding on a treatment.
  • Are appropriate and efficient in proposing therapies and interventions.
  • Develop rewarding relationships with patients.
  • Provide a continuous healing relationship over time.

Family Physicians

Who we care for:

  • Individuals and families
  • Women and men regardless of age or disease
  • Infants, children, and adolescents regardless of disease
  • Communities and public health
  • Global health
primary care delivers better health outcomes
Primary Care Delivers Better Health Outcomes

 mortality

 morbidity

 medication use

  • per capita expenditures
  • patient satisfaction
  • greater equity in health care

SOURCE: B. Starfield, et al., “The Effects of Specialist Supply on

Populations’ Health,” Health Affairs (March 2005); W5-97

the patient centered medical home as a preferred model of care
The Patient-Centered Medical Home as a Preferred Model of Care
  • Change is here!
    • Patients want more from the healthcare system and from their physician.
    • Purchasers of insurance (individuals, employers, government) are looking for quality and value.
    • Runaway healthcare costs must be addressed in ways that preserve and enhance access to high-quality, effective medical care.
    • There are ways to do both!
institute for health improvement triple aim
Institute for Health ImprovementTriple Aim

“The Institute for Healthcare Improvement (IHI) believes that focusing on three critical objectives simultaneously can potentially lead us to better models for providing healthcare.”

1. Improve the health of the defined population

2. Enhance the patient care experience (including quality, access and reliability)

3. Reduce, or at least control, the per capita cost of care

pcmh recognition programs
PCMH Recognition Programs
  • National Center for Quality Assessment (NCQA)
  • Accreditation Association for Ambulatory Health Care (AAAHC)
  • Joint Commission’s Primary Care Home Designation Standards
  • Utilization Review Accreditation Committee (URAC)
  • Private Payer Medical Home Recognition Programs
explore family medicine
Explore Family Medicine
  • Learn more about PCMH. (
  • Advocate for your patients.
  • Think about the future of healthcare. Are you learning the skills today that you will need for the changing healthcare system?
  • Visit Virtual FMIG. (
  • Join your local FMIG.
  • Join the AAFP. (
  • Get involved at the state and national level.