Learn More About Patient-Centered Medical Home

A Patient-Centered Medical Home or PCMH integrates patients as active participants in their own health and well-being. Patients are cared for by a trusted physician who leads the medical team that coordinates all aspects of patient care using the best available evidence and appropriate technology. This includes care for all stages of life: acute care, chronic care, preventive services and end-of-life care.

The PCMH is the foundation of health care improvement: better quality, low cost and improved experience of care. Care delivered by primary care physicians in a PCMH is consistently associated with better outcomes, reduced mortality, fewer preventable hospital admissions for patients with chronic diseases, lower utilization, improved patient compliance with recommended care, and lower Medicare spending.

Access to Care and Continuity

  • Healthcare for all
  • After-hours access
  • On-line services
  • Alternative visit types (electronic, telemedicine, group
  • Same-day appointments
  • Patient Portal

Plan and Manage Care

  • Preventive screening and services
  • Wellness promotion
  • Disease management
  • Comprehensive care for both acute and chronic conditions
  • Evidence based guidelines
  • Population management
  • Medication management
  • Patient participation
  • Family involvement

Practice Management

  • Cost-benefit decision making
  • Revenue enhancement
  • Financial management
  • Task designed by skill set
  • LEAN principles


  • Provider leadership
  • Mission and vision alignment
  • Effective communication
  • Change management
  • Personnel/HR management

Coordinate Care

  • Test tracking and follow-up
  • Referral tracking and follow-up
  • Collaborative relationships
    • Emergency Room
    • Hospital care
    • Behavioral health care
    • Pharmacy
    • Specialist care
  • Care transitions
  • Support self-care process
  • Community resources

Measure and Improve Performance

  • Continuous quality improvement
  • Patient/family satisfaction and feedback
  • Evidenced based decision support
  • Clinical outcomes analysis
  • Meaningful use requirements
  • Risk management
  • Regulatory compliance