Patient-Centered Medical Home


A “medical home” is an advanced model of primary care focused on the coordination of patient-centered care.  The medical home relies on a team of providers to meet a patients needs and to improve access to care (e.g., through increased communication between providers and patients; longer office hours; primary care in the home etc.). There is no uniform definition for a PCMH, though the National Committee for Quality Assurance (NCQA) offers accreditation and certification.  
Medical homes must have an interdisciplinary team supporting the practice and its patients. This team generally includes nurse case managers, social workers, care coordinators and/or community health workers or patient navigators. These teams may be physically located in the physician office or they may be virtual. In other words, the interdisciplinary team does not necessarily need to be physically onsite at the physician’s office, nor does it have to be limited to only serving that practice if it has capacity to serve other practices as well. Physician offices serving as medical homes may hire members or the care team or they may contract for their services on a full or part-time basis.

PCMHs assist patients during transitions of care, ensuring that the movement between sites of care is coordinated across providers and with the patient and family. PCMHs must also facilitate access to care, including through the use of extended hours, open access scheduling, and after hours care options.

Patient Population

All, although patients may be risk stratified to determine intensity of services

Typical Lead

Primary Care Physicians. PCMHs are typically physician-led primary care arrangements that offer team-based care. The medical team organizes the care across the “medical home neighborhood” and then leverages nonmedical supports and services when appropriate and necessary.  

Role of Home Health Home health providers may contract with physician groups to participate in the care team and provide a subset of the PCMH services, e.g., transition of care, care coordination, after-hours access to care, and assessments for purposes of risk identification, among other services. 
Reimbursement Model PCMHs generally receive a monthly per member per month (PMPM) care coordination fee from payers. Reimbursement rates depend on practice size, the level of sophistication of the practice with respect to care coordination tools and expertise, the anticipated coordination needs (intensity) of the patient, and other factors. Some payers also provide incentives for certain quality measures or improvements or share in savings achieved by enhanced coordination of care. These payments are made on top of (or in addition to) separate fee-for-service payments for medical visits.  

Physicians may contract with other providers, such as home health agencies, on either a PMPM or a fee-for-service basis depending on the services provided.
Minimum Infrastructure Requirements
  • Strong primary care base
  • Connectivity across providers for data sharing
  • Data analytics to identify high risk patients for specialized care coordination services
Variations For individuals with certain conditions specialty medical homes may provide the same suite of services but be managed by specialists, e.g., an oncology practice serving as a medical home for cancer patients.
Resources AHRQ PCMH Resource Page

Patient-Centered Primary Care Collaborative