According to the Agency for Health Research and quality, a patient centered medical home (PCMH) is defined as “a model of the organization of primary care that delivers the core functions of primary health care. This is a way to improve health by transforming how primary care is organized and delivered.” (Defining the PCMH) The goal of a patient centered medical home is to “provide high quality care across the full range of individual’s healthcare needs.” (White & Griffith, 2016, p.18) Primary care includes primary, secondary, and tertiary prevention types of care as well as well routine wellness visits that focus on disease and condition prevention and education. Primary prevention care involves activities that take place before the disease occurs to eliminate or reduce the disease from happening. Secondary prevention care involves activities that reduce the consequences of existing disease by early detection and treatment. Tertiary care is activities that reduce or avoid complications in an existing disease or condition.

One of the main characteristics that centers around a patient medical home is that there is a team of providers, nurses, and other health professionals that coordinates every patient’s care. When caring for a patient, a holistic approach is used to care for the entire body and not just the ongoing ailments. The patient has a relationship with each of these individuals on the care team. The team coordinates with each other if the patient needs to see a specialist and who the patient will be referred to inside the medical home as well as provide suggestions of treatments to give the patient until he or she can be seen by the specialist. One of the most well-known patients centered medical home in the U.S. is Kaiser Permanente, who was one of the first health systems to adopt this approach and be successful with it.

The American Academy of Family Physicians (AAFP) states that”transitioning to a patient centered medical home involves having a strong foundation to build an innovative and well-run organization to optimize efficiency and productivity. The checklist that this governing body has created involves staffing, financial management, health information technology, quality improvement, patient safety, and patient experience of care.” (PCMH Transition: Getting Started) All of these critical key components is what helps this type of dynamic model successful in the way patients receive care to improve outcomes. Staffing should include: developing physician leaders, defining staff roles and job details, allowing patients to choose their physician. Without physician leaders holding themselves and others accountable and having defined roles for every employee, an organization will not be successful in delivery quality care to individuals who need it. Financial management encompasses budgeting, forecasting, managing cash flows, and identifying opportunities for improvement to increase revenues and profits.

Health information technology plays a key critical role in a PCMH due to the nature of having a team of providers needing to communicate with each other and see updates in a patient’s chart in real time. Any device that is used in the practice needs to be encrypted concerning HIPAA privacy laws and be interoperable with other devices as well in case updates are made elsewhere. This includes complying with HIPAA and HITECH acts as well as developing a backup plan for when the systems malfunction and do not work properly. Quality improvement is one of the most crucial aspects to implementing this model so that processes can be streamlined to eliminate bottlenecks, reduce waste and errors. A quality improvement team needs to be established to work on various projects throughout the PCMH to ensure efficiency is ongoing. Patient safety has been a large concern in healthcare as of late when it comes to infections, falls, and prevention of any other potential errors. Each employee should be made aware of his or her role including job duties so that things do not fall through the crack. Patient experience involves making sure the customer has a great experience from the moment they make their appointment all the way through walking out the door. Patient satisfaction now plays a huge role in reimbursement methods with HCAHPS and GCAHPS scores. If a patient is enjoying their time spent at a medical facility, this will help with branding and marketing to other potential patients.


Agency for Healthcare Research and Quality. Defining the PCMH. 

Retrieved from

https://pcmh.ahrq.gov/page/defining-pcmh (Links to an external site.)Links to an external site.

Griffith, J. and White, K. (2016) The Well Managed Healthcare Organization. Health Administration press. Chicago, IL.

American Academy of Family Physicians. PCMH Transition: Getting Started. Retrieved from https://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/PCMHBasicsChecklist.pdf (Links to an external site.)Links to an external site.