255.004 Patient-Centered Medical Home

255.004

Patient-Centered Medical Home: A patient centered medical home (PCMH) is a primary care physician or team who ensures that patient care is accessible, coordinated, comprehensive, patient-centered, and culturally relevant through the direct provision, coordination, or arrangement of health care or social support services as indicated by the patient's individual medical needs and the best-available medical evidence.

Principles of a patient centered medical home (as articulated by AAFP, the American College of Physicians, Association of American Physicians, and American Osteopathic Association) are as follows.

Personal physician - each patient has an ongoing relationship with a personal physician trained to provide first contact and continuous and comprehensive care;

Physician-directed medical practice - the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

Whole person orientation - the personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life, acute care, chronic care, preventive services, and end-of-life care.

Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient's community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it, in a culturally and linguistically appropriate manner.

Quality and safety are hallmarks of the medical home, meaning (1) practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership among physicians, patients, and the patients' families; (2) evidence-based medicine and clinical decision-support tools guide decision making; (3) physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement; (4) patients actively participate in decision-making, and feedback is sought to ensure patients' expectations are being met; (5) information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication; (6) practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate they have the capabilities to provide patient-centered services consistent with the medical home model; and (7) patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication among patients, their personal physician, and practice staff.

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. It should (1) reflect the value of patient-centered care management work by physicians and nonphysician staff that falls outside of the face-to-face visit; (2) pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources; (3) support adoption and use of health information technology for quality improvement; (4) support provision of enhanced communication access such as secure e-mail and telephone consultation; (5) recognize the value of physician work associated with remote monitoring of clinical data using technology; (6) allow for separate fee-for-service payments for face-to-face visits (payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits); and (7) recognize case mix differences in the patient population being treated within the practice (SC-MCU Rep. 1-A-08; reaffirmed CM-MHPC Rep. 2-A-18).

Last Updated On

August 20, 2018