Patient Centered Medical Homes

A patient centered medical home changes what a primary care visit is for. Where visits have often focused on acute illness with much less attention to managing long-term conditions, the medical home model actively promotes prevention and gives patients the education and support they need to stay well.

What changes for the patient

The medical home puts the patient at the centre of a coordinated team. The practice takes responsibility for understanding the patient's needs, including the needs a patient may not raise during a short visit, and it works to keep chronic conditions under control rather than waiting for a crisis.

Prevention is part of that responsibility. Services such as vaccines are promoted actively, and patients are given information they can use to look after their own health between visits, which is a different emphasis from treating a problem only after it has developed.

Supporting the practice to change

Joining the programme brings practical support as well as a new payment model. Practices receive help with care coordination and practice transformation, delivered through a vendor engaged by the state, so that the operational work of running a medical home is supported rather than left to each practice to invent alone.

Care coordination payments are made on a per-beneficiary-per-month basis for attributed patients, in quarterly instalments. Those payments are intended to cover the ongoing costs of coordination and of the tools, technology and services a practice needs to operate as a medical home.

Payments and participation

The programme offers care coordination payments to support the running of a medical home and shared savings payments that reward quality care delivered efficiently. Both depend on meeting the programme requirements set out in the PCMH manual and on the performance shown in the practice's reports.

Participation is organised around enrolment, eligibility requirements and reporting, and each of those has its own guidance. A practice that understands the requirements before it enrols will find the reporting and the incentive calculations easier to follow.

A different way of working

Becoming a medical home is less a single change than a set of changes to how a practice works: how it identifies patients who need attention, how it follows up, how it coordinates with specialists and how it uses data to see whether its patients are improving.

The programme supports that change with webinars, a manual, additional resources and a provider portal where practices enter quality data and retrieve their reports. Together these give a practice the information and the assistance it needs to work in the new way.

A medical home also changes how a practice keeps track of its patients between visits. Rather than waiting for someone to call with a problem, the practice identifies the patients who need attention, whether because a chronic condition is not under control or because a preventive service is overdue, and reaches out. That proactive work is what turns a list of patients into a population whose care is actively managed, and the programme's reporting is designed to show whether it is happening.

Elements of the medical home model

• Care centred on the patient and coordinated across the team.
• Active promotion of prevention, including vaccination.
• Education that helps patients manage their own health.
• Care coordination payments on a per-beneficiary-per-month basis.
• Shared savings for high-quality, efficient care.
• Practice transformation support and detailed performance reporting.

Programme components for practices

The medical home programme has evolved since it was introduced, and payment amounts, requirements and reporting expectations change over time. Practices should confirm current details with the programme's official materials and the responsible state agency.