Patient-Centered Medical Home (PCMH)

Definition: According to the Agency for Healthcare Research and Quality (AHRQ), a PCMH is a model of the organization of primary care that delivers the core functions of primary health care.¹ They are also often called medical homes, primary care medical homes, medical neighborhoods, advanced primary care practices, and patient-centered health care homes. In adopting the PCMH model, primary care practices transform their practice to integrate the following functions.^2,3

• Comprehensive care: the PCMH is accountable for meeting a large portion of the patient's physical and mental health care needs, using a team of providers that can include pharmacists. These teams can be brought together on-site or virtually by linking to providers in the community.
• Patient-centered: the PCMH provides relationship-based health care using a whole-person approach. Patients in PCMHs are involved in establishing care plans and supported in managing their own care. This involves partnering with patients, families, and caregivers to understand each patient's needs, culture, values, and preferences.
• Coordinated care: the PCMH coordinates care across the healthcare system, including hospitals, specialty care, home-health care, community services and supports. There is a special emphasis on transitions of care as well as building strong communications between the PCMH, patients and caregivers, and other providers in the community.
• Accessible services: the PCMH is responsive to the patient's preferences regarding access to care by providing enhanced in-person hours, shorter wait times for urgent needs, around-the-clock telephone or virtual access to a care team member, and alternative methods of communication.
• Quality and safety: the PCMH demonstrates a commitment to quality and safety by engaging in evidence-based medicine, using clinical decision support tools for shared decision-making, engaging in performance measurement and the measurement of patients' experience and satisfaction, and practicing population health management. The PCMH shares safety and quality improvement data publicly.

Involved organizations/oversight: Many organizations evaluate and recognize practices as PCMHs, such as National Committee for Quality Assurance (NCQA), the Accreditation Association for Ambulatory Health Care (AAAHC), The Joint Commission, and the Utilization Review Accreditation Commission (URAC). Some payers provide accredited PCMHs opportunities to enter into alternative payment models or receive added incentives for coordinating care and meeting outcomes measures.

Guidelines for PCMH recognition and accreditation were developed by the American Association of Family Practitioners (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) and list the core principles as "a personal physician in a physician-directed, team-based medical practice; whole person orientation; coordinated and/or integrated care; quality and safety; enhanced access; and payment."³  

To be recognized as a PCMH, most practices have to implement changes that align with PCMH principles and then submit evidence to demonstrate the practice is providing care in line with PCMH standards during a practice review.⁴

Resources:

1. Agency for Health Research and Quality. Defining the PCMH. Available at: https://pcmh.ahrq.gov/page/defining-pcmh
2. Primary Care Collaborative. Defining the medical home: A patient-centered philosophy that drives primary care excellence. Available at: pcpcc.org/about/medical-home
3. American Academy of Family Physicians. Joint principles of the Patient-Centered Medical Home. Del Med J. 2008 Jan;80(1):21-2. PMID: 18284087.
4. NCQA. Available at: http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/why-pcmh/overview-of-pcmh

Contributing author:

Courtney Doyle-Campbell, PharmD, AHSCP-CHC
Western New England University

Last reviewed and updated 1/31/24 by Amber Mercuro (Rollins), PharmD, BCACP