Providers & Clinicians

Primary care clinicians regularly advise their patients to follow up with a specialist. Those following traditional methods of practice often find that their patients do not follow their instructions. A patient may not follow through because she doesn't fully understand why she should, due to a communication gap between the patient and the clinician resulting from inadequate appointment time, language barriers, cultural differences, or literacy levels. Another may get confused about how to navigate the insurance system and he will give up.  Whatever the reason, the patient's medical care is incomplete, and the clinician may never learn of this gap in care.

A patient-centered medical home, or PCMH, is a primary care facility following a team-based approach to healthcare. It is led by a patient's personal clinician, who provides comprehensive, continuous and coordinated care.

According to the American College of Physicians, "the PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety."

The PCMH practice works to make overcome any barriers that might prevent full communication with a patient in order for her to be a partner with her physician in her medical care. Often, this means that visits may be scheduled for longer than the traditional 15-minute appointment in order to allow the time to discuss treatment plans and testing options with the patient.

There are many benefits of being a PCMH clinician. The PCMH model provides many resources for giving patients comprehensive and high-quality medical care. There are significant financial incentives as well. Many major insurance companies, such as Aetna and Blue Cross Blue Shield, are growing aware that the PCMH model results in healthy patients that require far less expensive medical interventions do than those in traditional practices, and are increasing their reimbursements to clinicians who practice the PCMH model of care. Many major physician organizations have endorsed the PCMH as well because it enables them to practice medicine of the highest caliber without raising practice costs.

The Patient-Centered Primary Care Collaborative believes that, if implemented, the patient-centered medical home (PCMH) will improve the health of patients and the viability of the healthcare delivery system. One of the key elements of the PCMH is that health information technology (IT) is utilized appropriately and in a meaningful way to support optimal patient care, performance measurement, patient education, and enhanced communication. Health IT can play a significant role in providing a foundation for many key elements of the PCMH. Specifically, health IT can provide critical information about the patient to the entire care coordination team across all stages of care, support physician-patient communication, enable more timely and accurate performance measurement and improvement, and improve accessibility of the physician practice to the patient.

The Collaborative has established the Center for eHealth (CeH), to assure that a patient's relevant health data can be made available when needed at the primary care level from various sources. To learn more about the CeH, its current activities, and how you can get involved, please click here.

The Collaborative is further advancing the PCMH through its Center for Multi-Stakeholder Demonstrations (CMD),  which plays an active role as convener and supporter of demonstration projects and pilot programs designed to field the PCMH in various communities, regions and states. To learn more about the CMD, its current activities, and how you can get involved, please click here.  You can also click on the Pilot Guide map below to find a PCMH demonstration in your area.

Helpful links:

"Evidence of the Effectiveness of the PCMH on Quality of Care and Cost" (The Collaborative)

"The Business Model for the PCMH" (American College of Physicians)