Patient-Centered Medical Homes

Taking the Next Logical Step

Patient-centered medical homes are the next logical stage for enabling community health centers to meet more of our patients’ needs.

The promise of patient-centered medical homes (PCMHs) for patients of Southside Coalition members is

  • Comprehensive coordinated care and
  • The infrastructure for expanding the health care safety net in South Los Angeles by seamlessly integrating available care

This is why many of the Southside Coalition’s community health centers have begun the process of attaining certification as patient-centered medical homes. One member, T.H.E. Health and Wellness Centers, has already gained the Joint Commission Primary Care Medical Home certification.

Why Patient-Centered Medical Homes?
Basic Tenets of the Patient-Centered Medical Home
How Patient-Centered Medical Homes Work
Communication Is Prized in the PCMH

Why Patient-Centered Medical Homes?

Why is this necessary? Here are a few eye-opening facts:

  • Only 27 percent of adults in the United States say it’s easy to contact their primary care physician by telephone, get help after hours, or schedule immediate office visits.
  • Fifty percent of patients say they don’t understand what their doctor advised because they didn’t have enough time during their visit to get all their questions answered.
  • Doctors often must make decisions without knowing the results of care patients received in the hospital or at a specialist’s office.1

The patient-centered medical home aims to change these kinds of interactions by placing patients’ needs at the center of care. Placing patients’ needs at the center and structuring care to serve those needs — it’s a model that just makes sense.

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Basic Tenets of the Patient-Centered Medical Home

The concept of the patient-centered medical home evolved, resulting, in 2007, in a declaration of several principles by the American Academy of Family Physicians.2 In the PCMH:

  1. Patients should have an ongoing relationship with a physician.
  2. Care is designed to treat the whole person and is organized around each patient’s needs.
  3. Care is rooted in evidence-based medical models.
  4. Care is delivered by a team of health care professionals, which is headed by a primary care physician.
  5. Access to the care team is expanded through more flexible hours and more channels (patient portals, email, phone).
  6. Care is coordinated inside the medical home and with other care facilities, with the team taking responsibility for coordinating and following up on the patient’s care needs.
  7. Health information technology is used to improve coordination and overall efficiency of care for patients.
  8. Teams should advocate for their patients.
  9. Care is delivered in a manner that respects patients’ values and culture.
  10. Patients are involved in making decisions about their care and are accountable (when feasible) for following through.
  11. Ongoing quality improvement through feedback from patients and teams and tracking is central to providing the best care.

PCMHs offer a cost-effective infrastructure for eliminating health care disparities in medically underserved communities such as South Los Angeles. They promise better access to care, more preventive care, and higher quality of care, all for less cost.

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How Patient-Centered Medical Homes Work

In the patient-centered medical home, each patient’s health care needs are evaluated, leading to a plan for care. That care is determined by evidenced-based guidelines. For example, if a patient is determined to be prediabetic, treatment guidelines for preventing the onset of diabetes are incorporated into the patient’s care plan.

The PCMH model is particularly effective in managing chronic diseases, which account for 75 percent of today’s health care costs.3

In the PCMH, patients take an active role in their own health care. Patients and their families, primary care doctors, and the health care team form a partnership. The health care team may include physician assistants, nurses, nurse-midwives, dentists, mental health providers, social workers, health educators, and others.

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Communication Is Prized in the PCMH

Communication between patients and care providers is highly prized in the PCMH. The primary care team:

  • Coordinates all of their patient’s care
  • Helps patients manage chronic conditions
  • Tracks all medications and lab results to avoid duplication
  • Works with other health care professionals in specialists’ offices, hospitals, nursing homes, and other facilities
  • Assists patients in designing and monitoring their own wellness plan that supports healthy behavior

This partnership not only makes care more responsive to patients’ needs, it elevates the value of the care in the eyes of patients. Getting help navigating the health care system builds patients’ trust in their primary care team.

Patient feedback and tracked results are used to continuously improve the care provided.

A study of a Seattle group of clinics that have implemented patient-centered medical home care found it resulted in:

  • More patient satisfaction
  • Less physician burnout
  • Lower costs

Compared to its other clinics, the patients in the medical home experienced:

  • 29 percent fewer emergency visits
  • 6 percent fewer hospitalizations

Twenty-one months after implementation, they estimated savings of $10.3 per patient per month. They generated $1.50 for every $1 invested in the medical homes.4

See a comparison between primary care as it is practiced in many practices today and patient-centered medical care.

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Next: Find a Clinic

The Southside Coalition Story
Community Health Centers: Better Care, For Less
The Problems Community Health Centers Address
How Well Do Community Health Centers Really Work?
The South Los Angeles Safety Net: Filling the Gaps
How the Southside Coalition Is Strengthening the Local Safety Net

1Health Policy Brief. Patient-Centered Medical Homes. 2010. (Sept. 14).
2AAFP. Patient-Centered Medical Home.
3CDC. 2009 (Dec. 17). Chronic Diseases.
4Robert J. Reid et al. 2010.