The Changes Involved in Patient-Centered Medical Home Transformation


The patient-centered medical home model has been proposed by the major primary care professional societies as a way to achieve more effective, less costly care. Commonwealth Fund–supported researchers reviewed the professional literature and convened a panel of experts to identify characteristics of fully transformed medical homes and the necessary changes to infrastructure, organization, and care delivery that practices and clinicians must make to get there.

To become patient-centered medical homes, primary care practices must:

  • encourage engaged leadership to lead culture change and ensure that enough time and resources have been dedicated to the transformation effort;
  • institute a quality improvement strategy that establishes and monitors measures to evaluate improvement, ensures patients, families, providers and care team members are involved in quality improvement activities, and optimizes use of health information technology;
  • link each patient to a provider to create continuous, trusting relationships;
  • deploy organized care teams;
  • identify high-risk patients and ensure they are receiving appropriate, evidence-based care and case management services;
  • respect patients’ and families’ values and needs, encourage patients to expand their roles in decision-making, and communicate in a culturally appropriate manner;
  • ensure patients are able to reach their care teams at all times, whether by phone, e-mail, or in-person visits; and
  • coordinate care by linking patients with community resources, following up with patients after an emergency room visit or hospital discharge, and communicating test results and care plans to patients.
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