Patient Centered Medical Home is a team based health care delivery model led by a Physicians, Physician Assistants, or Nurse Practitioners, Pharmacists, Nutritionists, Social workers, Educators, and Care coordinators that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.
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The Patient Centered Medical Home is not limited to a single place or location. It is best described as a model of primary care that is patient centered, comprehensive, team-based, coordinated, accessible and focused on quality and safety that delivers the core functions of primary health care.
It is an approach to providing comprehensive primary care for children, youth and adults. The provision of Patient Centered Medical Home may allow better access to health care, increase satisfaction with care, and improve health.
The Patient Centered Medical Home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities.
It has been established through the cohesive efforts of the American Academy of Paediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).
Joint principles and functions of Patient Centered Medical Home?
There are 5 main joint principles and functions of Patient Centered Medical Home:
Coordinated and integrated care
Quality and safety
1. Comprehensive care: Patient Centered Medical Home delivers comprehensive care which requires team of physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
2. Patient centered: Partnerships between the patient, physicians and their family are an integral part of the medical home. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. 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. 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. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Patients are involved in decision making and provide feedback to determine if their expectations are met.
3. Coordinated and integrated care: Care is coordinated and integrated between complex health care systems, for example across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient’s loved ones and community-based services. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital.
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4. Accessible services: Patient Centered Medical Home delivers accessible services with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care.
5. Quality and safety: The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement 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.
Role of Health Information Technology (Health IT) in Patient Centered Medical Home:
The transition to PCMH is facilitated by innovative technologies, such as telemedicine for additional services, electronic medical records to document patients’ health needs, and online portals for electronic visits and communication between patients and providers. Electronic health record functionality enables real-time communication among team members which is likely to promote the team care approach. Implementing these technologies involves tremendous investment of funds and time from practices and healthcare organizations. Although Patient Centered Medical Home does not require such technologies, they facilitate its success, as care coordination and population management necessitated by the model are difficult to do without.
Health Information Technology (Health IT) plays an important role as a foundational support in building Patient Centered Medical Home.
Functions of Health IT in building Patient Centered Medical Home:
It collects, stores, and manages personal health information and aggregates data that can be used to improve processes and outcomes.
It supports communication, clinical decision making, and patient self-management.
It facilitates communication among providers, patients, and the patients’ care teams for care delivery and care management.
It collects, stores, measures, and reports on the processes and outcomes of individual and population performance and quality of care.
It supports providers’ decision making on tests and treatments.
It informs patients about their health and medical conditions and facilitate their self-management with input from providers.
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