A "medical home" is not a house, hospital or other building. It's a model of care where individuals use physician practices as the basis for accessible, continuous, comprehensive and integrated care.  Physicians who offer a medical home work with a team of health care professionals both inside and outside of their medical practices to offer patients evidence-based, comprehensive, and efficient care. They work in partnership with their patients to navigate the complex and often confusing health care system.

Recognition is growing among physicians, payers and policy makers that the patient centered medical home (PCMH) is an important opportunity to improve patient outcomes and reduce health care costs.

According to the PCMH Joint Principles, developed collaboratively with AAFP, AoA, and other leading primary care organizations, the PCMH is based on the following characteristics:

• Patients have a relationship with you -- their personal physician.
• Practice-based care team takes collective responsibility for patients' ongoing care.
• Care team is responsible for providing and arranging for the health care needs of all patients.
• Patients can expect care to be coordinated across care settings and disciplines.
• Quality is measured and improved as part of daily work flow.
• Patients experience enhanced access and communication.
• Practice uses EHRs, registries, and other clinical support systems.

PCMH RESOURCES

Legislation & Regulatory:

• CAFP Medical Home Bill (AB 1542) Adds a functional definition of "patient-centered medical home" to California law. With the growing popularity of this concept among consumers and providers, AB 1542 will ensure uniform standards of quality and access (Assembly Health Committee).

• Medicare Medical Home Demonstration Project: Later in 2009, it is expected that the Centers for Medicare & Medicaid Services (CMS) will announce the eight states and/or localities selected to participate in the new Medicare Medical Home Demonstration Project. Once selected, CMS will alert all medical providers and stakeholder organizations and will release application guidelines concurrently. Medical offices will need to apply individually. Increased payments may be as high as $100 per patient per month, depending on which criteria are met.

Powerpoint Presentations:

• Rich Roberts, MD, presentation at the CAFP 2009 ASA (April 2009)
• CAFP presentation at the 2009 Congress of Delegates (March 2009)
• CAFP presentation to the Santa Cruz Medical Society (February 2009)
• Patient Centered Primary Care Collaborative General Presentation

AAFP PCMH Resources:

• TransforMED Medical Home IQ Assessment
• PCMH Q & A
• Joint Principles on the Patient Centered Medical Home
• Featured articles, audio and video presentations

Research & Articles:

• California Family Physician (Spring 2009 edition): PCMH: What's all the Fuss? (Rich Roberts, MD); Building a PCMH (Bo Greaves, MD); NCQA: How to Know if You're Running a PCMH (Sandra Newman, MPH)
• Family Practice Management: Building the Case for the PCMH (Jan/Feb 2009);
• Achieving a patient-centered medical home as determined by the NCQA--at what cost, and to what purpose? (Annals of Family Medicine, Jan/Feb 2009)
• The Patient Centered Medical Home: History, Seven Core Features, Evidence & Transformational Change (Robert Graham Center, 2007)

Useful Links

• National Committee on Quality Assurance: Physician Practice Connections - Patient Centered Medical Home Recognition Program
• The Commonwealth Fund: Reports and publications, including data to support the effectiveness of the PCMH in reducing hospital admissions
• The Patient Centered Primary Care Collaborative: Poll data, consumer/purchaser materials, pilot projects, IT resource guides, and more
• Community Care of North Carolina: CCNC is a Medicaid program designed to cooperatively plan for meeting patient needs and to strengthen the community health care delivery infrastructure.
• American College of Physicians: PCMH Purchaser Guide, hill briefing, Congressional testimony, and more