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.