The American Academy of Family Physicians, the American College of Physicians and the American Academy of Pediatrics have endorsed the concept of the Patient Centered Medical Home (PCMH). The PCMH acknowledges that the best quality of care is provided NOT in episodic, illness oriented, complaint based care—but through patient centered, physician guided, cost efficient, longitudinal care that encompasses and values both the art and science of medicine.

In a medical home model, a physician leads a team that collectively takes responsibility for care, including coordinating care across the complex healthcare system, and through all types and stages of care. The principle also emphasizes care facilitation through patient registries (MDclick), use of information technology, advocacy for patients, evidence-based medicine, clinical support tools and performance measurement and improvement.

There are four cornerstones which are essential for the success of the PCMH model.
These are:

1. Primary care. The importance of primary care is based on research demonstrating its role in producing improved outcomes at lower cost. Primary care is defined as comprehensive, first contact, acute, chronic, and preventive care across the life span, delivered by a team of individuals led by the patients’ personal physician.

2. Patient-Centered Care- or the tailoring of care to meet the needs and preferences of patients. It urges active engagement of patients at all levels of care delivery with shared decision making by patients being more active, prepared and a knowledgeable participants in their care. Improving cultural competency among physicians will be essential.

3. New Model Practice. Building on innovations from the recent era of continuous quality improvement, patient safety, transparency, and accountability, using evidenced based processes of care including population based management, facilitated by patient registries and information technology.

4. Payment reform. Increased reimbursement to primary care physicians for the improved outcomes in health and for the added emphasis of care coordination.

The PCMH Model is guided by the following fundamental principles:

1. Personal Physician – A primary care physician provides continuous comprehensive care.

1. Physician Directed Medical Practice – The primary care physician will oversee and coordinate a practice team which will be responsible for care and coordination of healthcare services. Enhanced access to physician directed medical practice will include open scheduling, expanded hours and communication modalities between physician, practice staff and patient.

1. Patient Centered Care – The primary care physician will be responsible for providing and coordinating patient care within the practice and across specialties, including care provided throughout life stages, acute care, chronic care, preventive care and end of life care. In addition, care will be provided in a culturally and linguistic manner.

1. Coordination of Care – This insures that care provided will be integrated across specialties, healthcare delivery systems and the community. Care is facilitated and supported by health information technology, including but not limited to patient registries, electronic health records, health information exchanges and personal health records.

1. Quality and Safety – With the use of evidence-based medicine and clinical decision-support tools, continuous quality improvement in the practice will be achieved. This will be measured through ongoing physician supported feedback and reporting. In addition, physician and patient encounters will be enhanced through coordinated care planning and a patient self management process.

1. Payment – Reimbursement to the personal primary care physician and practice will recognize the added value of care provided in a PCMH and may be linked to higher payments, which are directly attributable to quality outcomes and payments for physicians operating a PCMH.

Heights Medical supports adoption of the PCMH in New Jersey and is actively restructuring areas of the practice to accommodate this process.  We believe that our patients will benefit from the PCMH concept in quality, support, care-planning and self-management.