Patient Centered Medical Home
Delaware Health Care Commission
Janice E. Nevin, MD, MPH
Chief Medical Officer
Christiana Care Health System
What is a Patient Centered Medical Home?

PCMH – History
1967 -American Academy of Pediatrics: Medical Home
1996 -Institute of Medicine, Committee on the Future of Primary Care: integrated accountable sustained partnership with patient
2001 -IOM, Crossing the Quality Chasm – 6 aims: safe, effective, Pt-centered, timely, efficient, equitable
2007 -Joint Principles of PCMH
PCMH -Joint Principles
Feb, 2007 -Joint Principles by ACP, AAFP, AAP, AOA
Personal physician -pt has 1 doc, 1st contact, continuous, and comprehensive care
Physician directed care -provider leads medical team
Whole person orientation -acute, chronic, preventative, home care & specialty services
Coordinated care -subspecialty, hospital, NH, uses registry, IT exchange, culturally sensitive
Quality & Safety -evidenced-based, CQI
Enhanced access -expanded hrs, e-visit, patient portal & group visits
Payment -should reflect added value to patients

Recognition Programs for PCMH Developed or Under Development
Comparison of PCMH 2008 and PCMH 2011
PCMH 2008 (9 standards/30 elements)
Access and Communication

Patient Tracking and Registry Function
Care Management
Continuity Between Settings

Self-Management Support
Electronic Prescribing
Test Tracking
Referral Tracking
Performance Reporting and Improvement
Measures of Performance
Patient Experience
Advance Electronic Communication

PCMH 2011 (6 standards/24 elements)
Access and Continuity
Electronic Access
Patient/Family Partnership
Practice Organization
Identify/Manage Patient Populations
Plan/Manage Care
Care Management
Medication Management
Self-Management Support
Track and Coordinate Care
Test/Referral Tracking
Performance Measurement and Quality Improvement
Measures of Performance
Patient Experience
Quality Improvement

AAFP -National Demonstration Project (NDP)
36 FP practices from across the country
June 2006 -June 2008
Randomized to facilitated learning vs. self-directed
The PCMH represents the essentials for better primary care, improved delivery of chronic care, and active partnership with an informed patient synergized by appropriate use of information and communications’ technology.
National Demo Project conclusions
1. Practice transformation is more than a series of changes and requires shifts in roles and mental models
2. The larger system can help or hinder
3. Practice adaptive reserve is critical to managing
4. Motivation of key practice members is critical
5. Developmental pathways to success vary considerably by practice
6. Practice change is enabled by the multiple roles that facilitators play

Ann Fam Med 2010;8(suppl 1):s45-s56.
Evidence of Cost Reduction
Recent studies estimate that if every American had access to a Medical Home, national health care expenditures would drop by 5.6% -translating into a national savings of at least $67 billion per year.1
States which relied more on Primary Care have:
Lower Resource Inputs (hospital beds, ICU beds, total physician labor, primary care labor, and medical specialist labor);
Lower Utilization Rates (physician visits, days in ICUs, days in the hospital, and fewer patients seeing 10 or more physicians);
Lower Medicare Spending (inpatient reimbursements and Part B payments).2
Community Implications – Published Results of PCMH Projects to Date
Community Implications -Published Results of PCMH Projects (cont.)
Care Team Transformation
Health Coach Functions

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