What is PCMH? 

A Patient Centered Medical Home (PCMH) is simply a better way – a more effective and efficient model of health care delivery. This new model produces better care and lower costs. Through a primary care physician, comprehensive care is coordinated to improve health quality and deliver better health outcomes. It also allows the care experience between patients and providers to improve, while reducing cost. A Patient-Centered Medical Home is a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH allows for the improvement of access, prevention, quality and coordination, as well as the experience of care for all patients by setting up systems and staff to better manage quality, continuity and costs of care for the most complex, highest-cost populations of patients. This model is centered around the patient where a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care.

Background on PCMH

The concept of PCMH was developed in the 1960's by the pediatric physicians, but has recently added the concept of applying PCMH standards to adult care. The American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA) developed the Joint Principles of the Patient-Centered Medical Home in 2007, that outlines a series of principles that define the characteristics of PCMH. The principles outline the model as having seven major components that include:
  • A personal physician - Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
  • Physician directed medical practice team -  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 that is coordinated and/or integrated - The practice should be able to provide coordinated/integrated care across all elements of the complex health care system and the patient's community. 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 -  Hallmarks of the medical home, the practice uses evidence-based and clinical decision-support tools to guide decision making concerning quality and safety.
  • Enhanced access-  Appropriately recognizes the added value provided to patients who have a patient-centered medical home.

PCMH Recognition and Accreditation

A number of nationwide PCMH recognition and accreditation programs exist. Although some practices are required to complete a recognition program (e.g., for participation in an accountable care organization or a PCMH incentive program), PCMH recognition for many practices is voluntary. You do not have to participate in a recognition program in order to begin or complete PCMH transformation.

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Get Started

Want to transform to a PCMH?
Your journey to patient-centered medical home (PCMH) transformation starts with the following foundational concepts, intended to help you lay the groundwork for a successful PCMH transformation.
Download these PCMH Checklist to get you started.

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