5 Key Functions of the Medical Home (2023)

Contents

• Comprehensive Care
• Patient-Centered Care
• Coordinated Care
• Accessible Services

The medical home encompasses five functions and attributes. This page includes white papers and briefs related to each area.

Comprehensive Care

The PCMH is designed to meet the majority of a patient's physical and mental health care needs through a team-based approach to care.

Briefs

Ensuring that Patient Centered Medical Homes Effectively Serve Patients with Complex Needs(PDF, 176 KB)
The PCMH model currently offers or coordinates many of the services required for patients with complex needs. This decisionmaker brief offers programmatic and policy changes that can help practices, especially smaller ones, better deliver services to all patients, including those with the most complex health needs.

White Papers

Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home(PDF, 181 KB)
The majority of PCMH demonstrations have not explicitly addressed the integration of mental health services into primary care. This paper examines successful approaches to delivering mental health treatment in primary care and PCMH settings.

Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions(PDF, 2.1 MB)
Patients who have complex health needs typically require both medical and social services and support from a wide variety of providers and caregivers. This paper discusses strategies that are needed to help primary care practices perform as effective medical homes to coordinate such services for patients with complex care needs.

Patient-Centered Care

The PCMH delivers primary care that is oriented towards the whole person. This can be achieved by partnering with patients and families through an understanding of and respect for culture, unique needs, preferences, and values.

Toolkit

Health Literacy Universal Precautions Toolkit
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.

Related Resources:

• Companion Implementation Guide(PDF, 404 KB)
  "Implementing the AHRQ Health Literacy Universal Precautions Toolkit: Practical Ideas for Primary Care Practices" is must-read for health literacy team leaders, practice facilitators, and quality improvement leaders. Based on the experience of diverse primary care practices, the guide supplements the toolkit by providing lessons learned in the course of implementing health literacy tools.
• Using Health Literacy Tools to Meet PCMH Standards(PDF,347 KB)
  This crosswalk identifies tools from the AHRQ Health Literacy Universal Precautions Toolkit that can be used to meet specific NCQA, The Joint Commission, and URAC PCMH standards.

Briefs

The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care(PDF, 154 KB)
The PCMH must fully engage patients to achieve its objectives, and this brief describes how decisionmakers can encourage a model of care that truly reflects the needs, preferences, and goals of patients and families.

Ensuring that Patient Centered Medical Homes Effectively Serve Patients with Complex Needs(PDF, 176 KB)
The PCMH model currently offers or coordinates many of the services required for patients with complex needs. This decisionmaker brief offers programmatic and policy changes that can help practices, especially smaller ones, better deliver services to all patients, including those with the most complex health needs.

Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home(PDF, 181 KB)
The majority of PCMH demonstrations have not explicitly addressed the integration of mental health services into primary care. This paper examines successful approaches to delivering mental health treatment in primary care and PCMH settings.

White Papers

Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions(PDF, 2.1 MB)
Patients who have complex health needs typically require both medical and social services and support from a wide variety of providers and caregivers. This paper discusses strategies that are needed to help primary care practices perform as effective medical homes to coordinate such services for patients with complex care needs.

Engaging Patients and Families in the Medical Home(PDF, 651 KB)
A key element of the PCMH model is engaging patients and caregivers in their care. This paper offers policymakers and researchers insights into opportunities to engage patients and families in the medical home and includes a framework for conceptualizing opportunities for engagement. It also reviews the evidence base for these activities, and offers examples of existing efforts as well as implications for policy and research.

Creating Patient-centered Team-based Primary Care(PDF, 972 KB)
Well-implemented team-based care has the potential to improve the overall quality and comprehensiveness of primary care. However, team-based approaches also may disrupt or change specific aspects of care, such as ongoing relationships, that are important to patients and providers. This paper offers a conceptual model and specific strategies to help primary care practices successfully transition to patient-centered team-based care.

Coordinated Care

The PCMH coordinates patient care across all elements of the health care system, such as specialty care, hospitals, home health care, and community services, with an emphasis on efficient care transitions.

Briefs

Care Management: Implications for Medical Practice, Health Policy, and Health Services Research(PDF, 185 KB)
Care Management Issue Brief. This issue brief highlights key strategies to enhance existing or emerging care management programs and summarizes recommendations for decisionmakers in practice and policy, as well as for future research.

Ensuring that Patient Centered Medical Homes Effectively Serve Patients with Complex Needs(PDF, 176 KB)
The PCMH model currently offers or coordinates many of the services required for patients with complex needs. This decisionmaker brief offers programmatic and policy changes that can help practices, especially smaller ones, better deliver services to all patients, including those with the most complex health needs.

White Papers

Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers(PDF, 83 KB)
Efforts to redesign primary care require multiple supports. Two potential members of the primary care team—practice facilitator and care manager—can play important but distinct roles in redesigning and improving care delivery.

Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions(PDF, 2.1 MB)
Patients who have complex health needs typically require both medical and social services and support from a wide variety of providers and caregivers. This paper discusses strategies that are needed to help primary care practices perform as effective medical homes to coordinate such services for patients with complex care needs.

Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home(PDF, 181 KB)
The majority of PCMH demonstrations have not explicitly addressed the integration of mental health services into primary care. This paper examines successful approaches to delivering mental health treatment in primary care and PCMH settings.

Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms(PDF, 715 KB)
"Neighbors" in the medical neighborhood include the medical home, specialists, hospitals, health plans, and other stakeholders. This paper describes how these neighbors could work together better, thus allowing the medical home to reach its full potential to improve patient outcomes.

The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care(PDF, 348 KB)
PCMH and ACO models of care delivery can work in tandem to increase the effectiveness of care coordination. Medical homes can directly coordinate services, while ACOs can facilitate and incentivize collaboration across various providers and organizations.

Reports

Care Coordination Accountability Measures for Primary Care Practice
This resource was developed in response to the need for measures for assessing or recognizing care coordination as it is carried out by primary care practices. The report lists care coordination measures selected systematically from AHRQ’s Care Coordination Measures Atlas (see above) that are well suited for use by health plans and insurers to assess the quality of care coordination in primary care practices and by primary care practices themselves to assess their own performance.

Care Coordination Measures Atlas
This resource lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination. The latest version of the Atlas was updated in June 2014.

Prospects for Care Coordination Measurement Using Electronic Data Sources
This report presents an assessment of the potential for measuring care coordination processes using data from electronic data sources, in particular from existing and emerging health information technology systems such as electronic health records, health information exchanges, and all-payer claims databases.

Accessible Services

The PCMH seeks to make primary care accessible through minimizing wait times, enhanced office hours, and after-hours access to providers through alternative methods such as telephone or email.

Quality & Safety

The PCMH model is committed to providing safe, high-quality care through clinical decision-support tools, evidence-based care, shared decision-making, performance measurement, and population health management. Sharing quality data and improvement activities also contribute to a systems-level commitment to quality.

White Papers

Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators(PDF, 1 MB)
This white paper describes approaches practice facilitators can take for encouraging primary care practices to undertake quality improvement (QI) activities. It presents a framework for engaging primary care practices in QI and provides practical strategies for gaining initial buy-in from practices, maintaining meaningful and sustained engagement in QI efforts, and working with multiple QI programs.

Related information:

• Quality Improvement Tip Sheet for Primary Care(PDF, 112 KB)
• Executive Summary(PDF, 85 KB)
• Quick-Start Guide(PDF, 285 KB)

Using Health Information Technology to Support Quality Improvement in Primary Care(PDF, 796 KB)
This white paper describes factors that support the use of health information technology (IT) for quality improvement (QI) in primary care, discusses exemplary cases, and makes recommendations to support and increase the use of health IT to improve the quality of health care delivery and population health outcomes.

Engaging Patients and Families in the Medical Home(PDF, 651 KB)
A key element of the PCMH model is engaging patients and caregivers in their care. This paper offers policymakers and researchers insights into opportunities to engage patients and families in the medical home and includes a framework for conceptualizing opportunities for engagement. It also reviews the evidence base for these activities, and offers examples of existing efforts as well as implications for policy and research.

Briefs

The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care(PDF, 155 KB)
The PCMH must fully engage patients to achieve its objectives, and this brief describes how decisionmakers can encourage a model of care that truly reflects the needs, preferences, and goals of patients and families.