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Patient Centered
Medical Home
New Model of Care
Steven E. Waldren, M.D.
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Agenda
History of Patient Centered MedicalHome (PCMH)
Current models
Current evidence
Challenges in US
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PCMH History
Concept started in 1960s bypediatricians (American Academy ofPediatrics) for special needs children
Future of Family Medicine Project
1999 - http://www.futurefamilymed.org
Multiple Names
New Model
TransforMED Model Medical Home Model
Patient Centered Medical Home
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http://www.futurefamilymed.org/http://www.futurefamilymed.org/http://www.futurefamilymed.org/8/9/2019 Patient Centered Medical Home_Waldren
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Adoption by Industry
Patient Centered Primary CareCollaborative (www.pcpcc.net)
Over 700 organizations promotingPCMH
Purchasers
Employers
Health Plans
Physicians Patients
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http://www.pcpcc.net/http://www.pcpcc.net/8/9/2019 Patient Centered Medical Home_Waldren
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PCMH Concept Joint Principles
AAFP, AAP, ACP, and AOA http://www.pcpcc.net/content/joint-principles-patient-centered-
medical-home
Personal physician
Physician directed medical practice Whole person orientation
Care is coordinated and integrated
Quality and safety are hallmarks
Practice advocates for patient
Evidence Based Medicine
Health IT
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http://www.pcpcc.net/content/joint-principles-patient-centered-medical-homehttp://www.pcpcc.net/content/joint-principles-patient-centered-medical-homehttp://www.pcpcc.net/content/joint-principles-patient-centered-medical-homehttp://www.pcpcc.net/content/joint-principles-patient-centered-medical-home8/9/2019 Patient Centered Medical Home_Waldren
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PCMH Model: AAFP View
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http://www.aafp.org/pcmh
http://www.transformed.com
http://www.transformed.com/http://www.transformed.com/http://www.aafp.org/pcmhhttp://www.aafp.org/pcmh8/9/2019 Patient Centered Medical Home_Waldren
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Access to Care & Information
Health care for all Same-day appointments
After-hours access coverage
Accessible patient information Online patient services
Electronic visits
Group visits
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Practice-Based Services
Comprehensive care for both acuteand chronic conditions
Prevention screening & services
Surgical procedures
Ancillary therapeutic and supportservices
Ancillary diagnostic services
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Care Management
Population management Wellness promotion
Disease prevention
Chronic disease management Patient engagement and education
Leverages automated technologies
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Care Coordination
Community-based resources Collaborative relationships
Emergency room
Hospital care
Behavioral health
Maternity care
Specialist care
Pharmacy Case management
Care transition
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Quality and Safety
Evidence based best practices Medication management
Patient satisfaction feedback
Clinical outcomes analysis Quality improvement
Risk management
Regulatory compliance
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Practice Management
Disciplined financial management Cost-benefit decision making
Revenue enhancement
Optimized coding and billing Personnel management
Facilities management
Optimized office design/redesign Change management
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Health Information Technology
Electronic medical record Electronic orders and reporting
Electronic prescribing
Evidenced based decision support Population management registry
Practice Web site
Patient portal
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Source: Health Affairs April 2010
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Many On-going PCMH Pilots
http://www.pcpcc.net/pcpcc-pilot-projects
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Summary of Evidence
http://www.pcpcc.net/content/pcmh-outcome-evidence-quality
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Evidence
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Challenges
No single PCMH Requires transformation of the
practice
Current Health IT is not designed tosupport PCMH
Variability and diversity of practices
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Summary
Achieving the PCMH will not beeasy, but can be done
Evidence predicts increased qualityand lower costs
Work is needed to identify thehighest value components of thePCMH
Current policy changes andindustry support is improving abilityto achieve PCMH model
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