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What is PCMH?

The NCQA defines the patient-centered medical home as a way of organizing primary care that emphasizes care coordination and communication to transform primary care into “what patients want it to be.” Medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care. Click here for a video that explains more.

The medical home encompasses five functions and attributes:

1. Comprehensive Care

As a patient-centered medical home, Grace Health meets the needs of our patients’ physical and mental health. This includes preventative and wellness care, acute care, and chronic disease management. In order to provide quality, comprehensive care, Grace Health has incorporated a team approach to treat each patient. Our teams may include physicians, advanced practice nurses, physician assistants, nurses, medical assistants, and care coordinators.

2. Patient-Centered

The patient-centered medical home provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing care plans.

3. Coordinated Care

The patient-centered medical home coordinates care with all of the entities in the health care system, including specialty care, hospitals, home health care, and community services and supports. This type of coordination is particularly critical during transitions between sites of care, such as when patients are sent to a specialist, need diagnostic testing, or are discharged from the hospital.

4. Accessible Services

The patient-centered medical home makes services more accessible and wait times shorter for those with immediate needs, includes enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team. The medical home practice adapts to patient’s preferences to provide the easiest access possible.

5. Quality and Safety

The patient-centered medical home focuses on quality and quality improvement by continuously improving patient outcomes by participating in activities such as using evidence-based medicine and clinical decision-support tools to guide shared decision making with patients and families, engaging in performance measurement and improvement, measuring and responding to patient experiences and patient satisfaction, and practicing population health management. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.