Person-Centered Medical Home

This page is designed to help you learn about the Person-Centered Medical Home (PCMH) initiative – an approach to providing comprehensive primary care for children, youth and adults. You will find important definitions, principles, and helpful information for understanding the PCMH concept and for determining if your practice or clinic should pursue PCMH recognition.

Department of Social Services Person Centered Medical Home (PCMH) Program

Posted on 6/21/13

Under the Department of Social Services’ (the "Department") new PCMH program, practices that demonstrate a higher standard of person-centered primary care service delivery will qualify for a higher level of reimbursement for primary care services from the Department. Qualified PCMH practices will also be eligible for additional financial incentives. Both HUSKY Health and Charter Oak Health Plan recipients will also be included in the PCMH program.

Practices that wish to pursue either full PCMH qualification or Glide Path status must complete a PCMH Application. Instructions for practices in each of the following categories are:

A practice that wishes to... Would need to...
Participate in the PCMH program and is already enrolled as a CMAP provider Complete the PCMH Application. Please contact the PCMH Administrator at 203.949.4194 or prior to completing the application.
Apply to participate in the PCMH program but does not participate in CMAP First apply to participate in the CMAP and sign a CMAP Enrollment Agreement as a prerequisite to PCMH Participation with the Department. Then, the practice must complete the PCMH Application.
Participate in the PCMH program, but has not yet obtained its NCQA PCMH recognition as a Level 2 or Level 3 PCMH Consider applying for Glide Path status, which offers practices that wish to participate in PCMH resources time to meet PCMH requirements with some enhanced reimbursement. Practices seeking Glide Path status must complete the PCMH Application and must further complete a Glide Path Application.
Decline the opportunity to participate in the PCMH program Continue to serve recipients on a fee-for-service basis in the CMAP under their current CMAP Provider Enrollment Agreement at the existing standard fee-for-service rates.

The Department will review each PCMH application, make a determination, and notify the practice regarding their PCMH status.

Source: PCMH application and instruction online at

Business Definition of a Medical Home

Posted on 6/21/13

A "medical home" is not a house, hospital or other building. Rather, it is a term used to describe a health care model in which individuals use primary care practices as the basis for accessible, continuous, comprehensive and integrated care. The goal of the medical home is to provide a patient with a broad spectrum of care, both preventive and curative, over a period of time and to coordinate all of the care the patient receives. The medical home model is promising because it has the potential to reduce overall costs in the U.S. health system.

Benefits of a Patient-centered Medical Home

  • A patient centered medical home (PCMH) is a model for care provided by physician practices that seek to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient symptoms with coordinated care and long-term health relationship.
  • Patients can easily make appointments and select the day and time
  • Waiting times are short
  • Email and telephone consultations are offered
  • Off-hour service is available
  • Patients have the option of being informed and engaged partners in their care
  • Practices provide information on treatment plans, preventative and follow-up care reminders, access to medical records, assistance with self-care, and counseling
  • These systems support high-quality care, practice-based learning, and quality improvement
  • Practices maintain patient registries; monitor adherence to treatment; have easy access to lab and test results; and receive reminders, decision support, and information on recommended treatments
  • Specialist care is coordinated and systems are in place to prevent errors that occur when multiple physicians are involved.
  • Follow-up and support is provided
  • Integrated and coordinated team care depends on a free flow of communication among physicians, nurses, case managers and other health professionals
  • Duplication of tests and procedures is avoided
  • Patients routinely provide feedback to doctors; practices take advantage of low-cost, internet-based patient surveys to lean from patients and inform treatment plans
  • Patients have accurate, standardized information on physician to help them choose a practice that will meet their needs

Source: Rogers E. Patient Centered Primary Care Collaborative. 2009

Patient-centered medical homes see higher provider satisfaction

Posted on 6/21/13

With the implementation of the Affordable Care Act recently getting the green light by the U.S. Supreme Court, expansion of one of its key tenets–the patient-centered medical home (PCMH)–has now reached a tipping point of having broad private- and public-sector support, according to a new report from the Patient-Centered Primary Care Collaborative (PCPCC).

In its follow-up report to one released in 2010, the PCPCC reports on results from medical-home initiatives during the past two years, with examples of PCMH programs contributing to better health, improved care and lower costs at participating practices, according to a post from AAFP News Now.

The model also has benefited healthcare providers, the report notes. For example, Seattle-based health system Group Health of Washington reported a 4.4 percent increase in provider satisfaction during study years of 2009-2010, as well as lower emotional exhaustion reported by staff (10 percent versus 30 percent among controls).

According to the report, the model will continue to pick up steam. "Major health plans and industry partners are embracing the PCMH model with enthusiasm by creating insurance plans and developing tools and resources contributing to the implementation of medical homes," the authors stated.

Indeed, a news story out New York this week describes how a new alliance between insurer Independent Health and 140 primary care providers, called Primary Connection, aims to replicate the successes achieved by similar PCMH programs around the country.

"The Primary Connection grew out of our frustration that we still couldn’t get good care for our patients," Donald W. Robinson, a family physician, told the Buffalo News, citing poor communication with specialists and poor transitions between doctors and facilities, among other problems the medical home model helps resolve.

With hopes that more National Committee for Quality Assurance-certified practices in Western New York will join the initiative, stakeholders are optimistic that the quality and cost benefits will be widespread. "We believe there will be savings in which a portion can go back to the doctors and a portion can go toward reducing the insurance premium," Michael W. Cropp, president and CEO of Independent Health, told the newspaper.


Principles of PCMH

Posted on 10/3/12

The Person-Centered Medical Home (PCMH) is an approach to providing comprehensive primary care for children, youth and adults. The PCMH is a health-care setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family.


  1. Personal physician – each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
  2. Physician directed medical practice – the personal physician leads a team of individuals at the practice level who collectively take responsibility for the on-going care of patients.
  3. 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. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.
  4. Care is coordinated and/or integrated across all elements of the complex healthcare system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally- and linguistically-appropriate manner.
  5. Quality and safety are hallmarks of the medical home:
    • Evidence-based medicine and clinical decision-support tools guide decision making.
    • Physicians in the practice accept accountability for continuous quality improvement through voluntary engagement in performance measurement and improvement.
    • Patients actively participate in decision-making and feedback is sought to ensure patient’s expectations are being met.
    • Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.
    • Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient-centered services consistent with the medical home model.
    • Patients and families participate in quality improvement activities at the practice level.
  6. Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff.
  7. Payment appropriately recognizes the added value provided to patients who have a person-centered medical home. The payment structure will be based on the following framework:
    • It will reflect the value of physician and non-physician staff person-centered care management work that falls outside of the face-to-face visit.
    • It will pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
    • It will support adoption and use of health information technology for quality improvement;
    • It will support provision of enhanced communication access such as secure e-mail and telephone consultation;
    • It will recognize the value of physician work associated with remote monitoring of clinical data using technology.
    • It will allow for separate fee-for-service payments for face-to face visits.
    • It will allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
    • It will allow for additional payments for achieving measurable and continuous quality improvements.

Source: American Academy of Family Physicians

Patient-Centered Medical Home Checklist to Becoming a PCMH: A checklist

Posted on 10/3/12

Build your medical home with a strong foundation in family medicine.
Apply this checklist to your practice.

Quality Measures

Are you using these clinical information systems:

  • Registries
  • Referral tracking
  • Lab result tracking
  • Medication interaction alerts
  • Allergy alerts

Your practice is a culture of improvement if you and your staff:

  • Establish core performance measures
  • Collect data for better clinical management
  • Analyze the data for quality improvement
  • Map processes to identify efficiencies
  • Discuss best practices

Does your practice use these checklists and reminders:

  • Evidence-based reminders
  • Preventive medicine reminders
  • Decision support

Do your care plans reflect:

  • An updated problem list
  • A current medication list
  • Patient-oriented goals and expectations

Patient Experience

Which of the following are you using to improve your patients’ access to care:

  • Same day appointments
  • Email
  • Web portal for Rx, appointments, or information
  • Referral to online resources
  • Non-visit based care and support

Does your practice support patient self-management through:

  • Motivational interviewing
  • Shared goal-setting
  • Home monitoring (when appropriate)
  • Group visits and support groups
  • Family and caregiver engagement

Clear communication requires:

  • Patient language preference
  • Cultural sensitivity
  • Active listening
  • Plain language, no jargon
  • Patient satisfaction surveys

Do you and your patients share in the decision-making process by:

  • Discussing treatment options in an unbiased way
  • Considering the patient’s priorities
  • Creating and revisiting follow-up plans

Health Information Technology

Are you taking advantage of these e-prescribing technologies:

  • Medication interaction checking
  • Allergy checking
  • Dosing alerts by age, weight, or kidney function
  • Formulary information

Do you have these evidence-based medicine supports in place:

  • Templates to guide evidenced-based treatment recommendations
  • Condition-specific templates to collect clinical data
  • Alerts when parameters are out of goal range
  • Home monitoring

Does your practice use a registry to facilitate:

  • Population health management
  • Individual health management
  • Proactive care
  • Planned care visits

Do you have the access you need to these clinical decision support tools:

  • Point-of-care answers to clinical questions
  • Medication information
  • Clinical practice guidelines

Is your practice connected to the health care community in these important ways:

  • Internet access
  • Quality reporting tools

Practice Organization

Rigorous financial management is essential. Are you:

  • Budgeting for forecasting and management decisions
  • Contracting with health plans from a selective and informed position
  • Managing the practice’s cash flow
  • Staying on top of accounts receivable

Does your practice offer individuals and teams opportunities for development through:

  • Ongoing education
  • Leadership training
  • Team meetings
  • Roles and responsibilities that are stimulating and rewarding
  • Shared vision and responsibility for quality of care
  • Value for the contributions of all individuals

Does the practice rely on data to drive decisions to:

  • Continuously improve quality and efficiency
  • Monitor supply and demand
  • Ensure adequate and fair distribution of work

Family Medicine Core Values

  • Continuous healing relationships
  • Whole person orientation
  • Family and community context
  • Comprehensive care

Source: American Academy of Family Physicians