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Patient-centered medical home: Making care coordination work for your practice

PCMH model brings challenges and rewards for physicians


The centerpiece of the patient-centered medical home (PCMH) model is a multi-disciplinary team that has everyone working at the top of their license to provide the right care, at the right time, in the most appropriate setting. But the success of a PCMH relies on a practice’s ability to track the care patients receive across the various components of the medical home using care coordinators and technology.

Judith Steinberg, MD, MPH, recently had a male patient who was diagnosed with AIDS. Making matters worse, his wife was found to be HIV-positive. The couple was overwhelmed and scared as their nightmare unfolded in the exam room. After discussing both diagnoses with the couple, Steinberg opened the exam room door, a behavioral health specialist stepped in, and counseling started immediately.

The case became more complicated when a cancer diagnosis was later added to the male’s list of problems. As his care plan was put into action, Steinberg was always aware of his health status even as he moved between inpatient, outpatient and specialty care settings because a care coordinator was in charge of making sure all the information made it into his record.

How the case was handled is a textbook example of what a PCMH is, says Steinberg, deputy chief medical officer for UMass Medical School’s Commonwealth Medicine division, which participated in a multi-payer PCMH demonstration project that ended on March 31.

“When I describe the patient-centered medical home to practices, providers, or to anyone—all of us are patients at one point or another—I like to say it’s really the way we, as patients, would like to see our care delivered,” says Steinberg.

“It makes such perfect sense that our care is focused on us as an entire individual, not as individual diseases or organ systems. That our care is well-coordinated and communicated across many settings and there’s an attention to quality and we are all partners in our care,” she added.

The biggest misnomer about medical homes, says Michael Meucci, director of transformation and improvements at the Burlington, Massachusetts-based healthcare consulting firm Arcadia Healthcare Solutions, is that being a PCMH means you received a certification. Practices with this mindset are more focused on passing a test than changing the way they practice, says Meucci.

Some practices are already doing things considered to be concepts of a medical home, not to check items off a certification checklist, but to provide better care, he says.

Five vital features of a patient-centered medical home

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Dr. Steve Feldman
I would love to learn more from those who do want to measure their PCMH patient satisfaction how and when they decide to use vendors. My company DrScore .com offers a low cost PCMH survey service.
May 23, 2014