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.

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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.

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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.

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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.

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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.

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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.

FAQs

What are the 5 attributes of medical homes? ›

The medical home encompasses five functions and attributes:
  • Comprehensive Care. ...
  • Patient-Centered. ...
  • Coordinated Care. ...
  • Accessible Services. ...
  • Quality and Safety.

What are the functions of patient-centered medical homes? ›

The patient-centered medical home (PCMH) model is an approach to delivering high-quality, cost-effective primary care. Using a patient-centered, culturally appropriate, and team-based approach, the PCMH model coordinates patient care across the health system.

What are the 5 key elements to patient-centered care? ›

Research by the Picker Institute has delineated 8 dimensions of patient-centered care, including: 1) respect for the patient's values, preferences, and expressed needs; 2) information and education; 3) access to care; 4) emotional support to relieve fear and anxiety; 5) involvement of family and friends; 6) continuity ...

What is the concept of the medical home? ›

A medical home is an approach to providing comprehensive primary care that facilitates partnerships between patients, clinicians, medical staff, and families. A medical home extends beyond the four walls of a clinical practice. It includes specialty care, educational services, family support and more.

What are the 5 pillars of medicine? ›

Five Major Moral Principles in Health Care:
  • I. NON MALFEASANCE.
  • II. BENEFICENCE.
  • III. UTILITY.
  • IV. DISTRIBUTIVE JUSTICE.
  • V. AUTONOMY.

What are the 5 A's of healthcare? ›

They grouped these characteristics into five As of access to care: affordability, availability, accessibility, accommodation, and acceptability.

What are the functions of healthcare facilities? ›

The following are six essential functions and responsibilities of healthcare facilities management:
  • Managing Day-to-Day Operations. ...
  • Compliance and Certification. ...
  • Ensuring a High-Quality Environment of Care. ...
  • Managing Construction Projects. ...
  • Maintaining Security. ...
  • Preventive Maintenance.

What are the 4 C's of patient-centered care? ›

Background: The four primary care (PC) core functions (the '4Cs', ie, first contact, comprehensiveness, coordination and continuity) are essential for good quality primary healthcare and their achievement leads to lower costs, less inequality and better population health.

What are the concepts of the medical home model? ›

The medical home is best described as a model or philosophy of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety.

What are the 4 P's of patient care? ›

The four Ps (predictive, preventive, personalized, participative) [3] (Box 21.1) represent the cornerstones of a model of clinical medicine, which offers concrete opportunities to modify the healthcare paradigm [4].

What are the 7 principles of care? ›

The principles of care include choice, dignity, independence, partnership, privacy, respect, rights, safety, equality and inclusion, and confidentiality.

What are the five key initiatives of the patient experience? ›

5 keys to improving patient experience
  • Streamline access to healthcare: ...
  • Demystify the financial implications of healthcare: ...
  • Make clinical decision making easier. ...
  • Support consumers as they care for others: ...
  • Help consumers maintain active, independent lives:
14 Jul 2021

What are the benefits of a medical home? ›

Accessible services – Patients receive the right care, at the right time, in the right place. Quality & safety – Medical homes provide care based on evidence-based guidelines to provide better quality of care, tracking outcomes and results, and continually working to improve care.

What is an example of the medical home model of care? ›

Because the medical home can be a physical or a virtual network of providers and services, HIT facilitates communication and information sharing among providers. For example, medical homes use electronic health records, which give providers instant access to patient information regardless of location.

What are the 5 Ps of ethical power? ›

Norman and I shaped our thinking around what we called The Five P's of Ethical Power: purpose, pride, patience, persistence and perspective.

What do the 5 pillars stand for? ›

The five pillars – the declaration of faith (shahada), prayer (salah), alms-giving (zakat), fasting (sawm) and pilgrimage (hajj) – constitute the basic norms of Islamic practice. They are accepted by Muslims globally irrespective of ethnic, regional or sectarian differences.

What are the 5 C's in health and social care? ›

What nouns beginning with C do you think might be essentially important in delivery of health and social care? So, the 6Cs are care, compassion, competence, communication, courage and commitment.

What are the six main functions of a facility? ›

Understanding the functions of facilities management
  • Maintaining & optimising facilities.
  • Streamlining processes.
  • Supporting people.
  • Managing projects.
  • Integrating technology.
13 Aug 2020

What are the 4 functions of hospital? ›

4. FUNCTIONS OF THE HOSPITAL  Patient care  Diagnosis and treatment of disease  Out patient services  Medical education and training  Medical and nursing research  Prevention of disease and promotion of health.

What are the four functions of health systems? ›

As shown in Fig. 4, in every health system organizations have to perform four basic functions: financing, provision, stewardship and resource gen- eration (human, physical and knowledge) (56).

What are the 4 P's nursing? ›

It's based on the 4 P's of nursing: Pain, Potty, Position and Periphery.

What are the 4 care values? ›

This is why is it so important for you to think about how you demonstrate the values in your applications and interviews.
...
The NHS values
  • working together for patients. ...
  • respect and dignity. ...
  • commitment to quality of care. ...
  • compassion. ...
  • improving lives. ...
  • everyone counts.

What are the 4 phases of care? ›

Four Phases of Care
  • Reduce pain.
  • Reduce nerve irritation.
  • Reduce tissue inflammation.
  • Increase flexibility.

What are the seven principles of a patient centered medical home? ›

The PCMH includes several principles: (1) an ongoing relationship with a personal physician for first-contact, continuous, and comprehensive care; (2) a physician-directed team that collectively cares for the patient; (3) whole-person orientation, including acute, chronic, preventive, and end-of-life care; (4) ...

What are the objectives of home based care? ›

To promote family and community awareness of disease prevention and care related to chronic illnesses;  To empower the clients, the family and the community with the knowledge needed to ensure long-term care and support;  To raise the acceptability of terminally ill patients by the family/community, hence reducing ...

What is the most purpose of home based care? ›

Home care is defined as the provision of health services by formal and informal caregivers in the home in order to promote, restore and maintain a person's maximum level of comfort, function and health including care towards a dignified death.

What are the 5 stages of the care planning process? ›

Stages of care planning

It includes assessing the patient's needs, identifying the problem(s), setting goals, developing evidence-based interventions and evaluating outcomes (Matthews, 2010).

What are the three main elements of patient care? ›

Three areas were reported as particularly important to patients: Pain management. Assistance with activities and daily living needs. Hospital surroundings and environment.

What are the 3 types of patients? ›

even in the early stages of your practice.
  • In general, there are three types of patients.
  • Patient #1: “I Have a Problem”
  • Patient #2: Check-Ups and Routine Visits.
  • Patient #3: Patients Looking to Switch Practices.
  • Marketing That Targets All Three Target Markets.
18 Nov 2015

What are 5 different types of care? ›

Types of Care
  • Residential Care.
  • Nursing Care.
  • Dementia Care.
  • Respite Care.
  • Convalescent /Post-Operative Care.
  • Continuing Care.
  • End of Life Care/Palliative Care.

What are the 8 values of care? ›

These are the guiding principles that help to put the interests of the individual receiving care or support at the centre of everything we do. Examples include: individuality, independence, privacy, partnership, choice, dignity, respect and rights.

What are the 9 values of care? ›

9 aspects:
  • Anti discrimination.
  • Confidentiality.
  • Rights of the individual.
  • Choice.
  • Dignity.
  • Culture and personal beliefs.
  • Protecting from abuse.
  • Effective communication.

What are the 5 steps to improving patient safety? ›

5 Factors that can help improve patient safety in hospitals
  1. Use monitoring technology. ...
  2. Make sure patients understand their treatment. ...
  3. Verify all medical procedures. ...
  4. Follow proper handwashing procedures. ...
  5. Promote a team atmosphere.
22 Aug 2018

What are key elements of care process? ›

What Are the Components of a Care Plan? Care plans are structured as a five-step framework: assessment, diagnosis, outcomes and planning, implementation, and evaluation.

What are the 6 aims of Healthcare Improvement? ›

The document recommends “six aims for improvement.” The aims are safety, effectiveness, equity, timeliness, patient-centeredness, and ef- ficiency. These aims are intended to iden- tify the fundamental domains that need to be addressed to improve the health care services delivered to individuals and populations.

What are three benefits of home based care? ›

Read on to find out about the importance of home care and how it can benefit you or your loved one.
  • Independence and empowerment. ...
  • Care at home. ...
  • Choice and control. ...
  • Improved health and wellbeing. ...
  • Easier to maintain your lifestyle and stay connected. ...
  • A safe environment. ...
  • Companionship. ...
  • Peace of mind.
18 Jul 2022

What is the purpose of home health care give an example? ›

Services provided by home health care professionals are tailored to the patient's individual needs. Examples include checking vital signs, assessing pain, monitoring food intake, managing medications, helping with basic hygiene, and ensuring safety in the home.

What are the principles of home based care? ›

There are four commonly accepted principles of health care ethics that providers follow to ensure optimal patient safety: autonomy, beneficence, non-maleficence, and justice.

What are the duties of a home nurse? ›

A Home Health Nurse, or Home Health RN, is responsible for traveling to a patient's home to administer their services and helping patients maintain their independence. Their duties include administering at-home IVs, changing dressings, cleaning wounds and updating Doctors about their patient's health.

What is another name for a medical home? ›

The medical home, also known as the patient-centered medical home (PCMH), is a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal health outcomes.

What are the characteristics of a medical home? ›

5 Key Functions of the Medical Home
  • Comprehensive Care.
  • Patient-Centered Care.
  • Coordinated Care.
  • Accessible Services.
  • Quality & Safety.

What are the four principles of the medical home strategy? ›

There are four commonly accepted principles of health care ethics that providers follow to ensure optimal patient safety: autonomy, beneficence, non-maleficence, and justice.

What are the attributes of health care quality? ›

Don Berwick describes six dimensions of quality in health care: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.

Which are characteristics of a patient centered medical home? ›

Characteristics of the PCMH model include: A strong relationship between every patient and a primary care physician. Coordination between the physician and the practice's team of clinicians. Coordination of the patient's care across various healthcare settings.

What are the three main element of medical care? ›

General practitioners (GPs), health insurance, and government health investment are the “three essential elements” of a PHCS among all its components.

What are the 7 principles of medical ethics? ›

This approach – focusing on the application of seven mid-level principles to cases (non-maleficence, beneficence, health maximisation, efficiency, respect for autonomy, justice, proportionality) – is presented in this paper. Easy to use 'tools' applying ethics to public health are presented.

What are the 5 domains of quality? ›

However, five domains are widely considered to be important to one's quality of life. These are; physical, psychological, social, economic, and spiritual domains (Cho, 2013) . Quality of life is said to be an important indicator of how the patients will respond to treatment and stay healthy. ...

What are all the 6 key elements of high quality care? ›

The six domains of healthcare quality outlined by the Institute of Medicine are patient safety, effectiveness, patient-centred, timeliness, efficiency, and equity. Each of these is important for ensuring that patients receive high-quality care.

What are the 4 key factors of health status? ›

Health is influenced by many factors, which may generally be organized into five broad categories known as determinants of health: genetics, behavior, environmental and physical influences, medical care and social factors. These five categories are interconnected.

What is an example of medical home model of care? ›

Because the medical home can be a physical or a virtual network of providers and services, HIT facilitates communication and information sharing among providers. For example, medical homes use electronic health records, which give providers instant access to patient information regardless of location.

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