The patient centered medical home (PCMH) model of care is a way to improve health care by transforming how primary care is organized and delivered. Early adopters of the patient centered medical home have seen a return on investment in quality and cost. Overall patient care improvements such as reduced appointment wait times, better access to care, enhanced care coordination, increased patient satisfaction, and reduction in emergency room visits and inpatient admissions support the model. Improved rates of disease management such as decreased HbA1c levels and increased immunization rates strengthen the endorsement. This physician-led team approach provides job satisfaction at the office level for both the physician and the team. However, these successes do not occur right away. Administrative and IT infrastructure, quality improvement processes, provider and employee buy-in all take energy, time and commitment.
Reaching out beyond the primary care office, the medical home coordinates patient care in what is called the patient centered medical home neighborhood (PCMH-N). Once a primary care practice masters the basics, it is important to start building the “medical neighborhood”. This involves discovering who is in your neighborhood that provides medical care for your patients. For example, who are the specialists, hospitals, pharmacists, and community/behavior health providers that also give services and care to patients? Collaborating and coordinating with these health care providers will further improve the quality, efficiency and safety of patient care and of the health care system.
Leadership is a key component to drive and sustain a culture of continuous quality improvement and improved patient care. Redesigning primary care through the eyes of the patient is challenging, but the benefits of healthier, engaged and motivated patients are worth all the effort. As our health care system moves from fee-for-service to payment models that reward higher value by managing the population, the team-based approach will become even more important. With growing private and public sector support, the patient centered medical home model is expanding to improve the health care delivery system for all patients and families.