What is a Patient-Centered Medical Home (PCMH)?

A patient care or centered model (PCMH) or medical home is a team-based health care delivery model led by a health care provider that is intended to provide comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.

The goals of a patient care model is to:

  • Allow better access to health care
  • Increase satisfaction with care
  • Improve health, and
  • Reduce health care costs.  

Care coordination is an essential component of the PCMH that requires additional resources such as health information technology and appropriately-trained staff to provide coordinated care through team-based models. Additionally, insurance companies compensate practices devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage further coordination.  

“A patient centered care model provides a personal relationship with patients, continuity of care, comprehensive care, accessibility, and quality.”   

My experience as a hospitalist and my residency training shaped how I wanted to develop my medical practice.  A hospitalist is a master of the resources and intrastructure of the hospital and transitioning the patient from the hospital to the outpatient setting. It is engrained from our training how to use resources effectively and get patients in and out the hospital with minimal complications or issues.  I used that background to develop how I wanted to create my medical practice.” ---Dr. Bertina Hooks

The characteristics of PCMH are the following:

  • Personal physician:  Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
  • Physician directed medical practice: The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
  • Whole person orientation: The personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals.
  • Care coordination: Care is coordinated and/or integrated between complex health care systems, across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient's loved ones and community-based services. This goal can be attained though the utilization of registries, health information technology, and exchanges, ensuring patients receive culturally and linguistically-appropriate care.
  • Quality and safety: Partnerships between the patient, physicians, and their family are an integral part of the medical home. Practices are encouraged to advocate for their patients and provide compassionate quality, patient-centered care.
    • Evidence-based medical decision making and with the use of decision-support tools.
    • Physicians' voluntary engagement in performance measurements to continuously gauge quality improvement.
    • Patient participation and feedback to determine if their expectations are met.
    • Utilization of informational technology to ensure optimal patient care, performance measurement, patient education, and enhanced communication
    • At the practice level, patients and their families participate in quality improvement activities
  • Enhanced access to care available through open scheduling, extended hours and new options for patient communication.

Payment reform:  Reimbursement must "appropriately recognize the added value provided to patients who have a patient-centered medical home."


Phoenix Health & Wellness PC
6600 Mercy Court, Suite 150
Fair Oaks, CA 95628
Phone: 916-299-6501
Fax: 916-581-6405
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