The Patient-Centered Medical Home (PCMH) arose from the need for a single clinician or practice to assume responsibility for coordinating the care for children with special health care needs.105
The purpose of the PCMH is to provide access to primary health care teams built around patients’ needs. It depends on appropriate team training and patient activation and is explicitly designed to enhance patient choice, quality, safety and efficiency. The seven core principles of the PCMH have been endorsed by the major primary care physician organizations and there is growing support for it among payers and Congress.106
The first six principles represent historic primary care ideals: a personal primary care physician, team-based care directed by a physician, whole person orientation, coordination of all facets of care, focus on quality and safety, and enhanced access to care.106
The seventh principle, payment reform, provides the means for implementing these principles.106
The PCMH represents a vision of future care for all patients,107
and many practices have already begun to adopt many of its features,108
including the Veterans Administration Health System.109
It offers particular promise for improving care for socially disadvantaged patients. The following idealized practice illustrates this.
A radically restructured primary care team might consist of one physician, one nurse practitioner (or physician assistant), a patient panel manager, and several registered nurses and medical assistants assigned a defined panel of patients. Tasks are distributed based on capability rather than traditional roles. Patient concerns requiring exploration of new symptoms and concerns are likely addressed in-person with the physician, whereas others may be accomplished through individual or group meetings with nurses and other health professionals.110
Professional language interpreters are universally available and funded. Phone visits,111,112
and secure email when feasible, are used for some routine concerns and to monitor progress. The Web can be used to allow direct patient access to their medical records including the ability to update health information113
as digital technology continues to diffuse to socially disadvantaged populations.114
. Importantly, a member of the team, perhaps a nurse, is always available to supplement electronic communications, for example, when patients need to understand test results that are made available via the Web.
These innovations reflect a radical redefinition of the roles of the health care team and patient. Patients are trained to provide critical health and health care updates through various modalities. While many patients communicate electronically with the health care team from home, user-friendly computer kiosks are available in the office for patients who lack reliable web access; these could also be used for in-office demonstrations and training.115
Patients are given access to and education in interpreting their own health records including test results -- a critical step towards patient empowerment.116
Many traditional physician responsibilities are distributed among the health care team to ensure that the physician's time is used wisely – for example, for the assessment of complex problems, discussion of a new diagnosis, a family meeting or deliberation over treatment options. A medical assistant updates medical data, reviews preventive care, and helps patients identify concerns prior to the physician visit.117
Routine preventive care is provided by the nurse through standing orders, allowing the physician to address more complex or unresolved concerns in greater depth.117,118
In the vignette, a certified interpreter would translate for Mrs S and the team would quickly pick up and address her poor preventive and chronic disease care.
Following physician-patient encounters, medical assistants or nurses routinely follow up by phone or in person to elicit the patient's understanding of the diagnoses and treatment plans, correct misunderstandings, and address barriers to care.119
In the case of Mrs S, the nurse, or perhaps even a team pharmacist, would identify less expensive blood pressure medications, link the patient with self-management groups and community resources, even community-based job training for Mrs S's husband.120,121
Ideally, Mrs S would feel more empowered to improve her health.
All abnormal laboratory results, preventive and chronic care are tracked using electronic registries and medical records.122
Importantly, all members of the care team are expected and paid to meet regularly for patient panel management, e.g. to review reports, recall patients, and implement changes in treatment.123
In the case of Mrs S, the nurse would identify her nonadherence based on review of her electronic medication refill history, and the team would develop a plan for addressing it.124
By considering these complex issues outside of time-pressured 15-minute visits, as a team - particularly a culturally diverse one - there is less risk for implicit bias, and more considered deliberation of treatment options using decision-support tools and evidence-based guidelines.123