Although the concept of a patient-centered medical home (PCMH) has been around for more than 50 years, the last decade has seen a revitalization of the PCMH model and an increase in its presence across the nation. The model’s popularity hinges on an approach to providing comprehensive primary care and redesigning healthcare delivery processes. This is accomplished through an emphasis on team-based care delivery, a whole-person approach to patient care, collaborative relationships between individuals and their physicians, and the use of evidence-based medicine and clinical decision support tools.
In 2007, four nationally recognized physician organizations identified seven principles considered foundational to the PCMH model:
1. Personal physicians
2. Physician-directed medical practices
3. Whole person orientation
4. Coordinated/integrated care
5. Quality and safety
6. Enhanced access
7. Payment reform
Although the foundational principles of the PCMH have been largely agreed upon, there is no clear model for how to create a successful PCMH. One of the most widely recognized models in place today is sponsored by the National Committee for Quality Assurance (NCQA), though there are numerous different demonstration and pilot projects in process across the country. As stated in the Journal of General Internal Medicine paper “Defining and measuring the patient-centered medical home”:
“…The context for operationalizing the PCMH is still evolving based on what is being learned in many ongoing demonstrations,” underscoring the importance of evaluating and incorporating unique geographic, demographic, and economic considerations into the design of any new care model.
Successful care delivery transformation projects, especially PCMH implementation and sustaining activities, require significant emphasis on healthcare analytics to inform quality improvement activities in addition to managing cost and utilization control efforts. The use of structured and routine analysis of information from healthcare claims enables both established organizations and newly developed PCMHs to receive ongoing feedback on process effectiveness and health outcomes, facilitating rapid-cycle process improvement across the organization.
PCMHs typically focus their analytic resources on operational process improvements and patient outcomes, with the goal of driving improvements in support of the “Triple Aim.” Successful organizations understand that routine and actionable information is the key to driving improvements. Examples of PCMH-focused analytic approaches being used across the country, which typically focus on cost, utilization, and quality, include but are not limited to the following: