Patient-Centered Medical Homes (PCMH)

What is a patient-centered medical home, or PCMH?
A Patient-Centered Medical Home is a team-based model of care led by a personal provider – physician, nurse practitioner or physician’s assistant – who delivers continuous and coordinated care throughout a patient's lifetime to maximize health outcomes.

The PCMH practice is responsible for providing for all of a patient's healthcare needs across the spectrum, including appropriately arranging care with other qualified professionals. This includes preventive services, treatment of acute and chronic illness, as well as assistance with end-of-life issues -- in short, any health care need you may need over your lifetime, thus treating the "whole person."

It is a model of practice in which a team of health professionals, coordinated by a personal provider, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety.

As the name implies, “patient-centered” is a way of saying that you, the patient, are the most important person in the health care system. You are at the center of your health care. “Medical home” is the approach to providing total health care. With your medical home, you will join a team that includes healthcare professionals, trusted friends or family members (if you wish) and, most importantly, you.

• Get to know your team.
  Your medical home team will know you. They can help you manage your total health care. You can see the same team each time you visit, and they can help answer your health questions.
• Work with other medical experts if needed.
  If you need to see a specialist, your team can keep in touch with the specialist to make sure you get the care you need.
• Track your health information using computers and electronic records.
  This is the best way for your team to have all of your records in one place.
• Reach your team when you need them.
  Your team will maintain convenient office hours for your appointments. They may also offer you other forms of communication to keep in touch with them.

• Be an active team player.
  Talk with your team about your health and any questions you may have. To best serve you, we need comprehensive patient information including your medications, visits to specialists, medical history, health status, recent test results, self-care information and data from recent hospitalizations, specialty care or emergency visits. The more we know, the better we can help. Share the successes and the challenges you’ve had with health care in the past. Tell your team how you feel about the care you are getting from them.
• Take care of your health.
  Follow the healthcare plan you and your team have agreed upon. Make sure you understand how to follow the plan. Set goals you can reach. Once you begin to see results, you and your team can discuss adding new goals.
• Talk openly with your team.
  If you are having trouble sticking with your care plan, tell your team about it. If you feel your care plan is not working, speak up. Tell your team what is not working so together you can make changes if needed.