What is a Patient-Centered Medical Home (PCMH)?
The patient-centered medical home (PCMH) is a model of care where patients have a direct relationship with a provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the care provided to the patient, and arranges for appropriate care with other qualified providers as needed.
By becoming a recognized PCMH, practices will improve safety, efficiency and quality in patient care and position the practice to take advantage of private or public incentive payments that reward patient-centered medical homes. Other benefits of recognized PCMH practices include team building among providers and clinicians, as well as precise patient care documentation regarding PCMH policies and procedures that are in primary care practices. Provider groups and healthcare organizations can visit their federal and state government and private insurers’ web sites for information on funding and reimbursement initiatives.
As your first step to this process, review the mission and vision of your practice organization. Develop a working definition of Patient Centered Care. Begin to develop, review and update documentation of your practice policies and procedures and do a thorough analysis of your operational work flows.
The following resource tools and manuals will support your organization’s journey toward developing a patient-centered medical home. Use the quick links below to jump directly to the information you want.
PCMH resources, including websites and newsletters that will provide continuous updates about PCMH initiatives including best practice examples and payment reform models.
PCMH practice assessment tools to assist you in engaging your organization in readiness to implement the PCMH model in the clinical practice.
PCMH recognition or certification programs
PCMH Resources
The Safety Net Medical Home Initiative
The focus of this initiative is to develop a replicable and sustainable implementation model for medical home transformation in safety net practices. Listed are links to key articles, tools and resources on patient-centered care, medical home and quality improvement topics.
Patient Centered Primary Care Collaborative PCMH Resources
The Patient Centered Medical Home Purchaser Guide and its short summary are insightful overviews of the patient centered medical home. The full Guide also includes supplemental resources such as detailed case studies, descriptions of pilot programs, and a draft request for information (RFI) and contract language for employers/purchasers to use with their health plans.
Health IT in the PCMH: a compendium of resources
This resource is a compendium of articles, case examples and tools for providers across the healthcare continuum to engage patients in their own care. Transforming Patient Engagement: Health IT in the Patient Centered Medical Home includes 15 core articles and 23 case examples to help primary care clinicians enhance patient engagement in the process of care delivery. This comprehensive resource was compiled by the Patient Engagement Task force of the PCPCC’s Center for eHealth Information Adoption and Exchange, and includes articles for a range of stakeholders—primary care providers, patients, caregivers, health IT developers, policy makers, employers and the broad spectrum of clinical team members who serve patients every day.
This is a free weekly e-newsletter created to deliver the latest news about the PCMH. Sponsored by the Patient-Centered Primary Care Collaborative and produced by Health2 Resources, H2RMinutes brings you targeted, timely news about the PCMH.
The Data Resource Center, funded by the Maternal and Child Health Bureau, is partnering with the American Academy of Pediatrics to help state and family leaders quickly access data on how children and youth in each state experience receiving care within a medical home. Measurement resources are available by state, practice, and policy.
The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009
This briefing document summarizes key findings from recent PCMH evaluation studies in a variety of settings ranging from integrated delivery systems to community-based office practices. The evaluations span privately insured patients, Medicaid, SCHIP and Medicare beneficiaries, and the uninsured. The evaluation findings consistently indicate that investments to redesign the delivery of care around a primary care PCMH yield an excellent return on investment.
Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes
This report introduces the goals of patient-centered medical homes. It also outlines the changes that medical practices would have to make in order to be considered a patient-centered medical home.
This report describes the patient-centered medical home initiatives that were launched by 17 states. The overall results listed provide positive reasons to continue developing PCMH through Medicaid programs.
Tool Used To Assess How Well Community Health Centers Function As Medical Homes May Be Flawed
This study analyzes the assessment tool developed by the National Committee for Quality Assurance. The report describes the tool’s reliability on qualifying a community health center as a patient-centered medical home.
PCMH Practice Assessment Tools
Patient-Centered Medical Home Assessment Tool (PCMH-A)
The Patient-Centered Medical Home Assessment (PCMH-A) is a self-assessment tool created by the Safety Net Medical Home Initiative to allow practices to gauge their progress in implementing each of the change concepts. The PCMH-A is an interactive PDF that can be downloaded, completed, saved and shared.
This guide discusses how to build partnerships that will help patients and their families understand the central role they play in their health and wellness. Ways of actively engaging patients and families in healthcare is also discussed.
This six part document provides answers to questions asked by health care leaders and patients. It provides a reason for the patient- and family-centered approach and outlines steps an organization can follow to create partnerships with patients and their families. An assessment tool for ambulatory care centers is also provided to help determine the degree that patient- and family-centered approaches are implemented in their current organzition. This document also provides guidance for beginning the process of identifying, recruiting, and sustaining the involvement of advisors.
Assessing, Diagnosing and Treating Your Outpatient Primary Care Practice
Found in the “Outpatient Primary Care” section, this workbook provides a guide for making a path forward towards higher performance. This workbook provides examples, tools and customizable forms to guide your clinical microsystem on a journey to develop better performance.
Primary Care Development Corporation Patient-Centered Medical Home Assessment Tool and Manual
The Primary Care Development Corporation, a not-for-profit organization providing financing and services to expand access to care in underserved communities, has released an update of its free online tool for assessment to meet 2011 NCQA PCMH recognition. PCDC’s tool helps guide practices through the NCQA medical home survey process. Providers and staff can assess how their practice operates compared to PCMH 2011 standards, including their use of electronic health records; patient and provider communication; data and patient outcomes reporting; workflow redesign; and care management and coordination.
Patient Centered Health Care Home (PCHCH) Program Toolkit
URAC (formerly the Utilization Review Accreditation Commission) has developed this toolkit to educate and guide health care practices, and/or their sponsoring health plans, insurers, and pilot programs, on how to transform practices into patient centered health care homes. This is an easy to follow, step-wise, organized framework to allow self-assessment and tracking of progress providing real time, self paced steps for building PCMH.
PCMH Recognition & Accreditation Programs
American Academy of Pediatrics
AAP has developed a national center for medical homes implementation. This website provides contacts for organizations that have developed or in the process of developing programs that recognize and/or accredit various health care organizations as medical homes according to specified sets of standards.
National Committee for Quality Assurance (NCQA)
NCQA is currently the most widely adopted evaluation model with 16,000 clinical sites recognized and currently expanding to military and FQHC clinics. The most recent 2011 standards emphasize behavioral health inclusion and incorporate stage 1 Meaningful Use of Electronic health record standards. The timeframe for recognition approval 30-60 days and 5% of clinical practice sites will be audited.
HRSA PCMH Initiative promotes its grantees (330H) to apply for NCQA recognition and will cover the costs for the NCQA survey tools and recognition fees. HRSA will provide a PCMH training/mentoring program. Organizations interested in HRSA support for initial NCQA PCMH recognition under the PCMHH Initiative must complete a Notice of Intent (NOI). The completed NOI must be submitted via email.
NCQA Patient-Centered Medical Home Standards and Guidelines
The Adobe PDF version of the PCMH Standards and Guidelines includes the requirements to
meet the standards, as well as explanations and examples. There are six PCMH 2011
standards, including 6 must pass elements, which can result in one of three levels of
recognition. Practices seeking PCMH complete a Web-based data collection tool and provide
documentation that validates responses.
NCQA Application for Patient-Centered Medical Home
The application materials include an overview of the PCMH program, eligibility criteria and pricing information.
NCQA Patient-Centered Medical Home Survey Tool
This web-based publication includes the Standards and Guidelines (the requirements to meet
the Standards as well as explanations and examples.) The Survey Tool also includes all the
information and the electronic data collection tool needed to prepare and submit materials to apply for recognition.
Joint Commission Primary Care Home Initiative
The Joint Commission is developing standards to expand the process of accrediting ambulatory health care organizations to those who are also interested in electing the Primary Care Home option. This initiative complements the Ambulatory Care Accreditation Program and is consistent with the new health care reform efforts to improve the coordination, quality and efficiency of health care services. This initiative is designed to combine the improvements in quality of care and patient safety achieved through accreditation with increased reimbursement from third party payers when the additional requirements of a Primary Care Home are met.
Accreditation Association for Ambulatory Health Care (AAAHC)
The Accreditation Association for Ambulatory Health Care, also known as AAAHC or the Accreditation Association is a private, non-profit organization formed in 1979 that develops standards to advance and promote patient safety, quality and value for ambulatory health care through peer-based accreditation processes, education and research. Accreditation is awarded to organizations that are found to be in compliance with the Accreditation Association standards. The AAAHC Medical Home On-site Certification Handbook provides specific standards for the Medical Home. The standards specify that a certified Medical Home is patient-centered, physician-directed, comprehensive, accessible, and provides for ongoing continuity of care.
