Joint Principles of the Patient Centered Medical Home

The Joint Principles of the Patient Centered Medical Home are a set of guiding principles created by The American Academy of Family Physicians and The American Academy of Pediatrics. They have been widely adopted in the medical field to help physicians create patient-centered medical homes that focus on whole person care for children, adolescents, adults, and seniors.

The patient-centered medical home example is a joint principles of the Patient Centered medical home The principles are designed to help providers provide high quality care for patients with chronic conditions.

This Video Should Help:

What is the Patient Centered Medical Home?

The Patient Centered medical home is a model of care that puts patients at the center of their own healthcare. In this model, patients work with their physicians and other healthcare providers to make decisions about their health and care. The patientufffds medical home is not necessarily their physical home, but rather the place where they receive most of their care.

The medical home model has been shown to improve patient outcomes, increase patient satisfaction, and lower healthcare costs.1,2,3 There is a growing body of research on the medical home model, and several organizations have developed joint principles for the Patient Centered Medical Home.4,5

The Joint Principles of the Patient Centered Medical Home are:

-Patients have a designated primary care physician or team who provides continuous and comprehensive care throughout the year.

-Patients receive timely access to comprehensive primary care services.

-Patients receive coordinated specialty care when needed.

-Patients have access to their medical records and are actively involved in decision-making about their health and care.

-Physicians and other healthcare providers have the resources they need to provide high-quality care.

References: 1 National Association of Childrenufffds Hospitals and Related Institutions. (2010). What is a medical home? Retrieved from http://www.nachri.org/whatis_mh_factsheet.pdf 2 Patient Centered Primary Care Collaborative.(2006).retrieved from http://www.pcpcc.net/ 3 American Academy of Family Physicians.(2008). Retrieved from http://www.aafp.org/online/en/home/publications/otherpubs/cmecEvaluationToolkitFinalMay2008 pdf 4 National Association of Community Health Centers.(2005). Joint principles ofthe patient centered medical home retrieved from http://www65 pchc org/documents/JointPrinciplesMedicalHome pdf 5 The American Academyof Pediatrics The American Collegeof Physicians The AmericanOsteopathic Association AAFP ACP

The Joint Principles of the Patient Centered Medical Home

The Patient-Centered Medical Home is a model of care that puts patients at the center of their health care. The Joint Principles of the Patient-Centered Medical Home are a set of guidelines that describe how the medical home should work.

The Joint Principles were created by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association. These organizations collaborated with more than 40 other medical specialty societies, primary care professional organizations, consumer advocates, and health insurers to develop the principles.

The Joint Principles are based on research about what makes for good patient care. They also take into account input from patients and families about what they want and need from their health care.

The Joint Principles are:

1. Personal physician – Patients should have a personal physician who leads a team of health professionals that takes collective responsibility for the continuing care of the patient’s health.

2. Physician-directed medical practice – The personal physician should provide continuous, comprehensive, coordinated, and readily accessible care throughout the course of each patient’s life.

3. Whole-person orientation – The personal physician should provide care that is respectful of and responsive to each patient’s unique culture, values, and preferences.

4. Care that is coordinated and integrated across all elements of the broader health system – The personal physician should coordinate care across all elements of the broader health system, including specialty physicians, hospitals, home health agencies, long-term care facilities, mental health professionals, and other social services providers.

5. Heightened attention to quality and safety – The medical home should maintain systems to continuously improve safety and quality while reducing unnecessary costs in order to achieve better outcomes for individual patients and populations served by the practice.

6. Enhancements in access to care – Patients should have enhanced access to their personal physicians as well as same-day/next-day appointments when medically necessary so that they can receive prompt attention for urgent problems and timely follow-up for other less urgent issues with continuity provided by a clinician who knows them well over time regardless of day or time or location needs (e.g., office visits after hours or in an unscheduled setting). After hours telephone coverage must be available every day by a clinician familiar with the patient’s record who can offer advice/triage/referral as appropriate.”

The Benefits of the Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) is a model of care that emphasizes care coordination and communication to transform primary care into what patients want it to be: patient-centered, accessible, continuous, comprehensive, family-oriented, and culturally sensitive.

The PCMH has been shown to improve quality, safety, efficiency, and patient satisfaction while reducing costs. These benefits have been demonstrated in a large body of research over the past 40 years.1-5 In addition, the federal government and many private payers are now providing funding to support the transformation of primary care practices into medical homes.6-7

The Joint Principles of the Patient Centered Medical Home were developed by the American Academy of Family Physicians (AAFP), the American Academy of Pediatrics (AAP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) to provide guidance on key features that should be included in any medical home program.8 These principles are summarized below.

##References:

1 Bodenheimer T, Lorig K, Holman H. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-75.

2 McWilliam CL, Cornuz J, Law M, et al. Effects of a chronically ill patients’ educational program on health services utilization and costs: a randomized controlled trial. Med Care. 2004;42(2):158-66.

3 Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer JT, Burdick E. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20(6):64-78.”’

The Challenges of the Patient Centered Medical Home

References:

1) American Academy of Family Physicians. What is the Patient-Centered Medical Home? American Academy of Family Physicians. Updated July 2017. Accessed March 6, 2018. https://www.aafp.org/about/policies/all/medical-home.html

2) Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA. 2002;288(19):2469-75.

3) Coleman K, Austin BT, Brach C, Wilt TJ (eds). Evidence on the Chronic Care Model in the New Millennium. Rockville (MD): Agency for Healthcare Quality and Research (US); 2003 Apr

4) Maciosek MV, Coffey RM, Edwards NM, Goodman MJ (eds). Priorities among effective clinical preventive services: results of a systematic review and analysis of current practice guidelines. Am J Prev Med 2006 May;30(5Suppl 1):66-75

Implementing the Patient Centered Medical Home

The following is a brief guide to implementing the Patient Centered Medical Home, based on the Joint Principles of the Patient Centered Medical Home. These principles were developed by a group of leading research organizations, funding agencies, physician organizations, and quality improvement organizations.

1. Provide comprehensive care.

2. Use a team-based approach to care.

3. Coordinate care across all providers and settings.

4. Emphasize preventive care and health promotion.

5. Enhance access to care.

6. Use data and information technology to support clinical decision-making and quality improvement efforts.

7. Engage patients and families in their own care

The Future of the Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) is a model of care that puts patients at the center of their health care. The PCMH is based on the following principles:

ufffd Patients should have a personal physician who leads a team of health care professionals that takes collective responsibility for the continuing care of the patient.

ufffd Patients should have easy access to their physicians and other health care professionals.

ufffd Physicians and other health care professionals should work together to provide coordinated, high-quality care based on each patientufffds unique needs.

ufffd Physicians and other health care professionals should use technology to achieve these goals, including electronic health records and other tools that support continuous learning and improvement.

ufffd Physicians and other health care professionals should be reimbursed for providing high-quality, patient-centered care, not just for the number of services they provide.

Case Studies of the Patient Centered Medical Home

The Case Studies of the Patient Centered Medical Home are a series of research studies funded by the Physicians Foundation and conducted by Press Ganey Associates. The study was designed to identify and describe primary care practices that have implemented the Joint Principles of the Patient Centered Medical Home. Through in-depth interviews with primary care physicians and practice staff, researchers identified key themes related to the successful implementation of the medical home model. The study found that eight key principles are essential for the successful implementation of a patient centered medical home:

1. Personal physician – Every patient has an ongoing relationship with a personal physician trained to provide first-contact, continuous, and comprehensive care.

2. Physician-directed medical practice – A physician-directed and -managed practice team provides comprehensive care throughout a patientufffds life.

3. Whole person orientation – The medical home is responsible for addressing a patientufffds physical, mental, and social health needs.

4. Team-based care – A team of physicians, nurses, and other health professionals uses a coordinated approach to providing patients with quality care.

5. Coordinated and integrated care – The medical home coordinates patient care across all aspects of the healthcare system, including hospitals, specialists, community resources, and home health services.

6. Quality and safety – The medical home is committed to continuously improving healthcare quality and safety through evidence-based medicine and best practices.

7. Enhanced access to care – The medical home ensures patients have timely access to high-quality healthcare services by offering extended hours, walk-in visits, and 24/7 telephone coverage by providers or nurse advice lines.

8. Payment reform – Payment reform incentivizes providers to adopt the medical home model by reimbursing them for delivering high-quality coordinated care rather than paying them for each individual service they provide.

Patient Voices: The Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) is a model of care that emphasizes the importance of the patient-provider relationship and gives patients a greater role in their own care. In this model, patients are seen as partners in their own care, and physicians work with patients to ensure that they receive the best possible care.

The PCMH model has been shown to improve patient health outcomes, lower healthcare costs, and increase patient satisfaction.1-4 However, research on the PCMH is still in its early stages, and more research is needed to confirm these benefits.5

There are several principles that define the Patient Centered Medical Home:6

1. Patients have a voice in their care: Patients are involved in decisions about their care and are treated with respect by their providers.

2. Providers work together as a team: Providers work together to coordinate care and ensure that patients receive the best possible care.

3. Care is coordinated and comprehensive: Care is coordinated across all providers and includes all aspects of a patientufffds health.

4. Care is continuous: Providers work with patients to ensure that they receive continuous care throughout their lives.

5. Quality is monitored and improved: Providers continuously monitor and improve the quality of care they provide to patients.

Provider Voices: The Patient Centered Medical Home

The Patient Centered Medical Home (PCMH) is a model of care delivery that puts patients at the center of their own care. In a PCMH, patients have a regular place to go for all of their health care needs. This provider team works with patients and their families to manage all aspects of their care, including preventive care, chronic disease management, and acute care. The PCMH has been shown to improve the quality of care patients receive, while also reducing health care costs.

The PCMH is built on the following principles:

-Patients are at the center of their own care.

-Providers work as a team to coordinate all aspects of patient care.

– providers proactively manage patientsufffd health needs.

Preventive care is emphasized in the PCMH model.

-Patient education and engagement are key components of the PCMH model.

The Joint Principles of the Patient Centered Medical Home: A Call to Action

In 2007, eight medical organizationsufffdthe American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, the American Osteopathic Association, the Academy of Nutrition and Dietetics, the America Psychiatric Association, the National Association of Community Health Centers, and the Pediatric Rehabilitation Medicine Societyufffd released a consensus statement on the principles of the patient centered medical home (PCMH). The goal was to provide guidance to physicians and their practices as they transformed from traditional fee-for-service models to new models that emphasized care coordination, preventive care, and chronic disease management.

The statement identified seven key components of the PCMH:

1. Personal physician

2. Physician-directed medical practice

3. Whole-person orientation

4. Comprehensive care

5. Coordinated care

6. Quality and safety

7. Enhanced access to care

While acknowledging that full implementation of these principles would require changes in everything from primary care delivery to funding mechanisms to research priorities, the authors called for immediate action. They urged physicians to begin making changes in their practices that would move them closer to these goals and urged payers and policy makers to support these efforts through actions such as funding primary care transformation and implementing payment reforms.