Patient Centered Medical Home (PCMH)

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What is a Patient Centered Medical Home (PCMH)?

A PCMH is a model that has promise in improving healthcare by changing how primary care is organized and delivered.  PCMH uses a team-based approach to provide appropriate and timely care, which leads to safer, more effective care and improved patient-provider relationships.

What are the components of a PCMH?

  • Comprehensive Care – the PCMH is responsible for meeting the majority of patients’ physical and mental healthcare needs.  These needs range from prevention services to chronic illness and injury care.  To meet patients’ needs, PCMHs use a team-based approach that includes traditional members such as doctors, physician assistants, nurse practitioners, and nurses; and nontraditional members such as pharmacists, nutritionists, social workers, patient navigators, and community health workers.  Smaller PCMHs may choose to use virtual teams to provide access to the providers and services they do not offer in house.
  • Patient Centered – PCMH provides relationship-based healthcare focused on the patient as a whole.  This is done through the PCMH collaborating with core members of the health team, patients and their families.  Effective partnering is accomplished by respecting each patient’s unique needs, culture, values and personal preferences.  The partnership enables patients and their families to be informed members of the health team, allowing them to help establish the patient care plan.
  • Coordinated Care – A PCMH is able to coordinate a broader scope of healthcare including specialist care, hospital care, home health, and community services.  This coordination allows for better patient care as the patient transitions from one phase of care to the next, such as a patient returning to their home for home healthcare from the hospital.  These transitions during care are a critical component of the patient’s healthcare.
  • Continuous Care – The patient receives care from the same primary care professional whenever possible.  If the patient moves to a different primary care practice, the professional will support the patient in finding another medical home practice and will provide the care plan and any other relevant information in the medical record to the new practitioner.
  • Compassionate Care – the focus is always on the patient’s well-being and comfort.
  • Culturally Effective Care – primary care professionals find ways to serve patients of all backgrounds, including those who speak little or no English.
  • Accessible Services – A PCMH provides improved access to services.  This improved access includes shorter wait times for patients with urgent needs, increased in-person appointment hours, 24-hour access to electronic or telephone based care, and enhanced communications methods such as email.  These improvements allow the PCMH to adapt to the patient’s needs and preferences.
  • Quality and Safety – PCMH’s are committed to quality and quality improvement by continually participating in activities including using evidence-based medicine, providing clinical decision making tools to help patients make decisions about their care, measuring performance and addressing areas of improvement, measuring and addressing patient satisfaction, and committing to population health management.  These activities ensure PCMHs are operating with high level of quality and safety.  The quality and safety information and any improvement activities are shared publicly to demonstrate PCMHs commitment to quality and safety.

For more information visit:

Pennsylvania Department of Human Services

Patient Centered Medical Home Resource Center

Pennsylvania Medical Home Initiative

National Center for Medical Home Implementation

Patient-Centered Primary Care Collaborative