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What does PCMH mean?


Defining elements of a Patient-Centered Medical Home:

1. Comprehensive Care

  • Provide physical and mental health care needs, including prevention and wellness, acute care, and chronic care.

  • Team approach: physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.

  • In small practices this may be a virtual team, linking services within the community.

2. Patient-Centered

  • Model of shared decision making with patients and families.

  • A holistic approach tailored to the needs, values, culture, and preferences of each individual.

3. Coordinated Care

  • Coordinate services across the spectrum from acute hospitalization, to specialty visits to home care.

  • Serve as a bridge when the patient transitions back to the community after hospitalization.

4. Accessible Services

  • Patients must have access to the care team outside of traditional office hours.

  • Access to appointments for acute issues in a timely manner.

  • Availability of care in-person, by telephone, or even email depending on preferences of the patient.

5. Quality and Safety

  • Ongoing quality improvement activities and the use of evidence-based practices.

  • Collect data on performance measures and participate in public reporting.

PCMH is a solution to many of our challenges in health care: fragmented care, duplication of services, excessive use of specialty care, and lack of preventive services.

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