What is a Patient-Centered Medical Home? (2025)

Abstract

The concept of Patient-Centered Medical Home (PCMH) originated with the specialty of pediatrics to provide care to children with complex illness. Similar concepts were uncovered when researchers looked at high quality yet low cost health systems. PCMH concepts have been adopted by primary care professional organizations and are being supported by multiple other organizations. The implementation of PCMH practices by individual physician groups is accelerating with new payment models and other key drivers.

What is a Patient-Centered Medical Home?

Patient-Centered Medical Home (PCMH) is an oft-mentioned but poorly understood as a concept.1 The concept also has some aliases; the Affordable Care Act mentions Medical Homes numerous times; others refer to Advanced Primary Care Practices. While definitions may vary, the past two decades have brought much interest in PCMH concepts. As evidence of this interest, using PubMed elicited 17,430 articles on Patient-Centered Medical Home, most published since 1994.2 Three days later, the same search elicited an additional 31 new articles. In this paper, we will discuss the origins of and driving forces behind the PCMH concept, what practices look like in a PCMH model, and what physicians engaged in PCMH work can expect.

Origins of the PCMH Concept

PCMH roots are traced Medical Home for children with special health care needs (CSHCN). As initially envisioned, the Pediatric Medical Home would be the source of patient information for CSHCN, representing an early attempt at coordinating care for these children who often saw multiple and disconnected physicians and providers.3,4 The American Academy of Pediatrics (AAP) may have been the first to use the term Medical Home when it published its 1967 version of the Standards of Child Health Care. The AAP soon recognized that fragmented care was a problem affecting not just the CSHCN, but nearly all children. In 1977, the AAP began advocating that Medical Home implementation could benefit all children. Although there were earlier attempts, notably in North Carolina, the first state-wide child health plan recognition occurred in Hawaii, under the leadership of Calvin Sia, MD. Dr. Sia’s ongoing championing of the medical home concept has led many to view him as the father of the medical home. These early efforts with pediatric medical homes demonstrated the medical home feasibility and benefits of coordinated care.

Early Research Supporting Primary Care PCMH

Researchers studying health outcomes note that, for populations in highly-developed countries, more generalist physicians means lower cost and better outcomes for the population. The World Health Organization definition of primary care, based on the 1978 Declaration at Alma-Ata, has been used to define primary care.5 That definition is the provision of: first-contact access for each new need; long-term person-focused care (not disease focused); comprehensive care for most health needs; and coordination of care when care must be sought elsewhere. Barbara Starfield’s work, in particular, revealed that where there is a higher supply of primary care physicians, there is an association with lower costs, more equity in care, and higher quality of care.6, 7

The mere presence of more primary care physicians does not explain the improved outcomes associated with more primary care physicians. Some systems with substantial numbers of primary care physicians achieve better results than others. Research work began to explore what processes underlie these higher performing systems. Using the findings of Starfield and others, health care policy organizations, notably the Robert Wood Johnson Foundation and the Commonwealth Fund, commissioned studies that have further explored the value of primary care in providing high-quality, low-cost health-care. Not surprisingly, systematic delivery of primary care is associated with improved health outcomes, reduced costs and improved quality of health care. The desired outcomes occur when primary care physicians are working in systems that support first-contact care, long-term personal continuity of care, and coordinated care in a comprehensive manner. Such systems have collectively come to be associated with PCMH practices.

What Defines APCMH?

The American College of Physicians, American Academy of Family Physicians, American Osteopathic Association, and the American Academy of Pediatrics adopted Joint Principles of the Patient-Centered Medical Home in 2007. In their statement, these organizations held that a recognized PCMH should demonstrate processes and outcome performance in the following general areas as quoted in the following:

  1. Personal physician-each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.

  2. Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.

  3. Whole person orientation – the personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals.

  4. Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services).

  5. Quality and safety are hallmarks of the medical home.

  6. Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

  7. Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.

The Agency for Healthcare Quality and Research (AHRQ), which often functions as a testing arm of Centers for Medicare and Medicaid Services (CMS) has adopted a slightly different definition, one which is more amenable to non-physician practitioners. In the AHRQ definition, the requirement for a personal physician and the practice to be physician directed are missing. Also absent in the AHRQ statement is any explicit commitment to payment reform. Nonetheless, the CMS movement to value-based purchasing relies on many of the processes found in the PCMH. Of note is that Health and Human Services has found that the use of Advanced Primary Care Practices seems to be a more palatable and understandable term than medical home. The stated reason is that many patients associated medical home with facilities, such as a nursing home. One has to suspect that non-physician providers found dropping the term medical desirable. There is little available evidence that a system of care led by non-physician providers will perform at comparable levels with prior studies of physician-led PCMHs. The Agency appears to be bowing to political pressure in dropping physician leadership as a qualifying standard. The National Committee for Quality Assurance (NCQA) has adopted a set of standards for practices leading to recognition as a PCMH. The NCQA recognition is arguably the most widely accepted evidence of performance as a medical home. Joint Commission and other accrediting agencies offer standards programs to recognize PCMH practices as well.

Who Benefits From A PCMH?

For payers and patients, the PCMH offers improved value through lower cost and higher quality of care. Health systems that rely on inpatient beds being filled for revenue have difficulty adapting to PCMH, which lowers such costs. For patients, the PCMH provides lower cost, higher quality of care, improved access, and coordination of care. But what about physicians?

Physician Benefits in a PCMH

A startling number of physicians, but in particular family medicine and general internal medicine physicians, report significant distress, dissatisfaction with work-life balance, and burn-out, much higher than what is present the general population.8, 9 This level of distress urgently calls for system change and restoration of health to our physician workforce. Figure 1 is a typical day drawn from the authors’ experience of PCMH versus usual practice. It is little wonder that the typical fee-for-service practice can lead to burnout! The system changes associated with full implementation of PCMH concepts do much to restore and rejuvenate physicians and staff.10, 11 In a study of 23 high performing practices, Sinsky describes this as joy in practice.12 Changes in practice processes associated led these 23 practices to have physicians who reported not only satisfaction, but actual joy in practice. Physicians that intended to leave were retained, and physician satisfaction in practice has markedly improved.

Figure 1.

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A primary care physician leading a PCMH accepts not only the care of the patient seen in the office, but also reaches out to her community of patients or patient panel. This process of empanelment is an important building block in attaining continuity and providing PCMH services. The number of patients in a physician’s panel varies according to factors such as age, presence of chronic illnesses, and other acuity factors. Unfortunately, there is not a widely accepted or tested means of risk adjustment for outpatient acuity, thus determining appropriate panel sizes for physicians remains more art than science. Many electronic medical records (EMR) remain frustratingly unsophisticated in providing registries of patients that would benefit from enhanced chronic care and preventive measures. Many practices establish care – manager positions to contact patients regarding needed preventive services and follow-up care for chronic illness. Population management is generally a new skill to be acquired by physicians. Residency programs are increasingly training that provides skill in population management.

A hallmark of successful PCMH practice is team-based care. Each member of the practice strives to work at the top of their license a way of saying that tasks should be performed by those whose skill and regulations permit. Thus, the physicians time should be generally spent on diagnosis and prescription of treatment. Tasks, such as initial history taking, that do not require physician level of training and licensure are completed by others. Where possible protocols that enable others to act are developed. For instance, under a physician-directed protocol, and LPN or MA can initiate immunizations, ordering of labs, etc. Effective delegation and standardized protocols allow physicians to engage in tasks only the physician can perform and provides new time to engage in effective patient care and related activities. Surprisingly, delegation to skilled non-physicians is often resisted by physicians. This lack of skill in delegation may be due to misunderstanding the skill of others on the team and training that emphasizes individual skill and accountability rather than teamwork. Medical school and residency programs are addressing leadership and delegation skills through enhancing interdisciplinary training and, in primary care programs, explicitly training residents in skills necessary for effective PCMH practice.

Specialty physicians interacting with a primary care PCMH should expect and support the PCMH requiring timely responses to consult requests and reports, including if the patient did not keep a scheduled appointment. The PCMH physician will expect dialogue about further testing and treatment plans. Most follow-up will be conducted by the PCMH and return visits to the consultant should be only for those matters which cannot be accomplished at the PCMH. Information about the patient should be relayed in a manner that is easily incorporated into the EMR.

Finance and PCMH

The financial benefits associated with providing a PCMH concerns practicing physicians. Because of differing definitions, differing implementation, and other factors, there are few reliable studies about practice costs. To date, physician requests for return on investment numbers have been met with the response, if you have seen one PCMH you have seen one. Nevertheless, it seems clear that PCMH practices will fare well under the recently passed Medicare Reform Law and CHIP Reauthorization Act of 2015 (MACRA). Advanced payment models (APM) promulgated by MACRA provide substantial payment advantages to PCMH qualified practices, including potentially lower costs the due to waiver of Merit-based Incentive Payment Plan (MIPS) compliance and associated costs. Larger physicianled organizations participating in risk-sharing models have seen substantial revenue, such as Group Health in Washington have seen shared savings of $10.30/month/patient.13 Current MGMA statistics indicate a decrease in staff associated with PCMH models, a surprising statistic that bears further evaluation and time. (Personal access via http://data.mgma.com/DataDive/) It may well be that costs lower over time dues to a lessened reliance on face-face care (reduced need for staff) and on improved quality of care (reduced burden of uncontrolled illness) as has been demonstrated in international models.

To support widespread adoption of the PCMH model, most policy writers advocate for continuation of some face-to-face visit based fees, per-member-per-month payment for empaneled patients, payment for meeting quality measures, and periodic, at least annual, shared savings distributed to the PCMH practices. Many insurers are offering incentives for physicians to engage in PCMH implementation. For examples, in Kansas City, Blue Cross and Blue Shield offers enhanced payments to practices recognized as a PCMH using the criteria of NCQA. For practices involved in Accountable Care Organizations, the ability to provide value and reduced cost it critical to the success for the ACO and generally translates into additional revenue to the physicians in the PCMH practice.

Regulations continue to be written for Medicare APM, but PCMH practices will be favorably treated under the law. Other APM models outside of the PCMH have less certainty about their impact.

Summary

The PCMH model offers value to patients and payers and satisfying practice to physicians. Developing a PCMH practice requires physicians to exercise delegation and leadership skills, work in a team-based environment, and support population management beyond patients being seen at the practice facility. A well managed and supported PCMH can improve quality of care, lower costs of care, and provide primary care physicians with joy in their practices. While payment models are under development, well-managed PCMH practices will be in a better financial position than most other practices.

Biography

Michael L. O'Dell, MD, MSHA, MD, FAAFP, MSMA member since 2010, is Associate Chief Medical Officer at Truman Medical Center and Professor and Chair of the Department of Community and Family Medicine at the University of Missouri - Kansas City.

Contact: odellm@umkc.edu

What is a Patient-Centered Medical Home? (2)

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Footnotes

Disclosure

None reported.

References

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