Patient-centered medical home

From :

AHRQ defines the PCMH as having five key domains:



Comprehensive Care The PCMH is designed to meet the majority of a patient’s physical and mental health care needs through a team-based approach to care.
Patient-Centered Care Delivering primary care that is oriented towards the whole person. This can be achieved by partnering with patients and families through an understanding of and respect for culture, unique needs, preferences, and values.
Coordinated Care The PCMH coordinates patient care across all elements of the health care system, such as specialty care, hospitals, home health care, and community services, with an emphasis on efficient care transitions.
Accessible Services The PCMH seeks to make primary care accessible through minimizing wait times, enhanced office hours, and after-hours access to providers through alternative methods such as telephone or email.
Quality & Safety The PCMH model is committed to providing safe, high-quality care through clinical decision-support tools, evidence-based care, shared decision-making, performance measurement, and population health management. Sharing quality data and improvement activities also contribute to a systems-level commitment to quality.

The PCMH model is built upon three foundational supports:

Foundational Support


Health IT Health IT can support the PCMH model by collecting, storing, and managing personal health information, as well as aggregate data that can be used to improve processes and outcomes. Health IT can also support communication, clinical decisionmaking, and patient self-management.
Workforce A strong primary care workforce including physicians, physician assistants, nurses, medical assistants, nutritionists, social workers, and care managers is a critical element of the PCMH model. Amid a primary care workforce shortage, it is imperative to develop a workforce trained to provide care based on the elements of the PCMH.
Finance Current fee for service payment policies are inadequate to fully achieve PCMH goals. Providers are not routinely compensated for care coordination or enhanced access, contributions of the full team are often not reimbursed, and there is no incentive to reduce duplication of services across the care continuum. Payment reform is needed to achieve the pot

Tools and Resources for Implementing the PCMH



Developing and Running a Primary Care Practice Facilitation Program: A How-To Guide Practice facilitation is increasingly considered a promising means for improving primary care. This guide provides information on how to start and run a facilitation program to work with primary care practices on quality improvement activities, particularly those oriented toward primary care redesign and transformation.


  1.  NCQA Patient-Centered Medical Home guidelines
  2. ACP – Patient-Centered Medical Home
  3. AAFP – Patient-Centered Medical Home
  4. AHRQ – Patient-Centered Medical Home
  5. Primary Care Development Corporation PCMH
  6. Patient-Centered Primary Care Collaborative
  7. National Center for Medical Home Implementation
  8. American Academy of Pediatrics – Start Building Your Medical Home
  9. Commonwealth Fund – Patient Centered Care

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