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The Patient-Centered Medical Home

Michael Bell, PA

The patient-centered medical home (PCMH) model is a program that provides superior and more cost effective medical care. It has been piloted in several areas of the country and is gaining momentum. Essentially, it is a program that provides an interdisciplinary team approach to patient care, facilitating partnerships between patients and physicians. The team (medical neighborhood) would typically consist of doctors, physician assistants/nurse practitioners, dietitians, pharmacists, and social workers. This interactive team is designed to enhance an individuals’ access to comprehensive and coordinated healthcare. The system is built upon the practice of evidence-based medicine with quality improvement and performance measures to assess and monitor patient outcomes. The model has two important elements: an essential reliance on electronic information technologies and a revised payment system to compensate providers based on quality of patient outcomes instead of volume of services.

The PCMH is more than a great idea or concept…it is revolutionary in its approach to medicine and certainly may change the face of medicine and our current healthcare system. To the point, two components of the PCMH model are highlighted below.


  • Delivery and Accessibility:  Patients will be given care by culturally competent staff; in addition to benefiting from access to expanded hours, same-day scheduling, e-visits, and patient portals for improved information sharing. As a note, Community Care of North Carolina, involving over 1,300 community-based practice sites, reported the following quality measures in its population served by this program: a 40% decrease in hospitalizations for asthma, a 16% lower ER visit rate, and a 15% reduction in diabetes.
  • Transferability and Continuity of Care:  The use of the electronic medical record and information technologies allows for instant communication between the primary care physician and the supporting medical neighborhood involved in each patients care.  Patient information is used by care coordinators to allow for communication between providers and subspecialty care, hospitals, rehabilitation facilities, home health agencies, nursing homes, and/or other community-based care resources. This approach is used to provide continuity across the full spectrum of care from onset of illness to recovery and wellness.


IParticipating practices will be evaluated on patient outcomes and held accountable for continuous quality improvements through voluntary engagement in performance measures (with the results transparent and available for anyone to see).  On the quantitative side, some changes will occur in reimbursement; specifically, a component of payment will be quality driven. The new financial framework will result in a better value…defined as better outcomes at less cost…for patients, employers, and government agencies that purchase healthcare insurance.
This program may indeed change healthcare in America.  It will not be easy or quick, but the practices that have participated in the pilot programs to date have all noticed a two-fold benefit: 1) improvement in the overall health of their communities, and 2) a reduction in the cost to the system. The patient-centered medical home program may just be the medicine needed to save the life of our healthcare system.



About the Author

Invigor™ashe Staff Writer: Michael Bell, PA, obtained his Physician Assistant degree from MCP Hahnemann University; and is Board Certified. For over ten years he has been practicing acute in-patient and rehabilitation medicine in both private practice and mid-size hospitals.


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