Patient Centered Medical Home (PCMH)

The terms medical home, patient centered medical home, health home, and other versions are often used interchangeably to refer to models for care management or primary care delivery.

While these terms share common origins and underlying concepts, it can be confusing to understand how specific programs differ from one another. The Kansas Healthcare Collaborative developed a white paper, “Medical Home Concept Versus Medicaid Health Home,” to help health care providers and other stakeholders understand the similarities and differences between two models currently being implemented in Kansas, the Medicaid Health Home and the Patient Centered Medical Home.

→ The KHC team includes Quality Improvement Advisors that are trained and Certified Content Experts in the Patient Centered Medical Home model. They are available to assist Kansas practices interested in or currently working toward becoming a Patient Centered Medical Home. For more information, please contact KHC Program Director Rosanne Rutkowski at (785) 235-0763 or This email address is being protected from spambots. You need JavaScript enabled to view it..

Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) is a promising approach to improving primary care delivery. The PCMH aims to improve quality, reduce cost, and improve the experience of patients, caregivers, and health care professionals.

As defined by the Agency for Healthcare Research and Quality, the medical home encompasses five functions and attributes:

1. Comprehensive Care

The primary care 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. Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. 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.

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2. Patient-Centered

The primary care medical home provides health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. 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.

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3. Coordinated Care

The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team.

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4. Accessible Services

The primary care 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. The medical home practice is responsive to patients’ preferences regarding access.

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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. Sharing robust quality and safety data and improvement activities publicly is also an important marker of a system-level commitment to quality.

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