Patient-Centered Medical Home

Becoming a successful accountable care organization depends on many factors. One of the most important is the concept of the “patient-centered medical home.” A patient-centered medical home (or simply, “medical home”) is a medical office in which a team of healthcare professionals, typically led by a primary care physician, works together to improve the health of patients and eliminate unnecessary use of the emergency room and hospital. Efforts are 24/7, proactive, and extend beyond the traditional primary care office.

A medical home focuses on three key areas: disease prevention, including lifestyle modification and safety education; chronic disease management, such as blood pressure control and diabetes management; and transitional care during acute illness that requires specialists, hospitalizations or palliative care.

Why is establishing a medical home a good idea? First, medical homes support accountable care. Compared to conventional care delivery, health systems in which medical homes are the cornerstone of care produce higher levels of quality at lower cost – the guiding principle of accountable care. Medical homes also fulfill an important role in a changing healthcare environment that elevates the importance of preventive care and counseling. An expert recently estimated that to provide all of the recommended preventive care and counseling to an average patient population, a primary care doctor would have to work more than 18 hours a day – and that doesn’t include time needed to manage acute illnesses, injuries or chronic diseases.

This is where the medical home’s team approach fits perfectly. Effective patient care management now requires attention to transitions of care and more oversight outside the physician’s office and by non-physician professionals with specialized expertise. Health educators, social workers, nutrition consultants, nurse specialists and advanced care providers are vital members of the medical home team – and necessary to produce the best patient outcomes. The point person of such coordinated care is the medical home nurse. This designated professional functions as the liaison between team members, specifically between the primary care doctor and other professionals providing care outside the primary office.

While the medical home concept is new to patients and families – especially those patients who have grown accustomed to being treated exclusively by their family physician – there are a number of important benefits. A medical home provides the framework for proactive care that focuses more deliberately on prevention and lifestyle changes that lead to long-term health and well-being. In fact, some would argue that medical homes are essential in managing health through all phases of life. By working with a healthcare team, patients also have more professionals with specialized expertise to call upon for guidance. As we move toward a value-based accountable care environment, the medical home will play an important role in delivering high-quality patient care in more cost-effective ways.

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