What is it?
A patient centered medical home (PCMH) is a model of primary care that aims to strengthen the doctor-patient relationship by replacing episodic and reactive care with coordinated, comprehensive and continuous care. At the core of this model is a team-based approach that places equal emphasis on the patient’s medical and non-medical needs.

Team-Based Care
A key feature of the PCMH is its use of care teams that consist of physicians, nurse practitioners, physician assistants, nurses, health educators and other health professionals. These teams work collaboratively to address all aspects of a patient’s physical and mental health. Core responsibilities include preventive care management, around-the-clock access to care, care coordination across specialties and health settings as well as patient and caregiver education.

Focus on the Whole Person
Unlike traditional primary care which focuses solely on acute, episodic illnesses, the Patient Centered Medical Home operates under a whole-person philosophy. Providers assess and treat patients’ medical, behavioral and social needs through a comprehensive approach. This includes screening for health risks, social determinants like housing instability and behavioral health issues like depression. Care plans are developed with the input of the full care team to address all facets impacting a patient’s well-being.

Enhanced Access and Continuity
A hallmark of the PCMH model is enhanced and expanded access to healthcare services. Beyond in-person appointments, patients can utilize alternatives like phone or virtual visits, email consultations and prescription renewals. Providers promote continuity by being “on call” 24/7 and serving as the central point of contact for issues that arise. Care is not limited to a single visit but rather sustained over time through ongoing monitoring and management between clinical encounters.

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