The Patient-Centered Medical Home (PCMH)

The patient-centered medical home (PCMH) is a model for strengthening primary care through the reorganization of existing practices to provide patient-centered, comprehensive, coordinated, and accessible care that is continuously improved through a systems-based approach to quality and safety (Lipson, Libersky, & Parchman, 2012). The principle of “Coordination of Care” would be most challenging to achieve. This principle involves coordination of access across all elements of the healthcare system, such as subspecialty care, hospitals, home health agencies, nursing homes, and the patient’s community (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

For example, it is more efficient under current fee-for-service payment mechanisms to identify and document the health problems of a complex-needs patient and then refer that individual to a specialist for diagnosis and treatment (Lipson et al., 2012). Coordinated care promotes the concept of having all patients’ care being coordinated by clinician-led teams, who provide for all the patient's health care needs and coordinate treatments across the health care system. Brangman and Hansen (2010) in a letter to Dr. Donald Berwick, administrator of the Centers for Medicare & Medicaid Services presented facts regarding physician Medicare reimbursement fees which disclosed that physician fees did not cover the extra costs of comprehensive geriatric assessment, nor did they cover the cost of additional time required to communicate with patients with cognitive impairments or to examine those with physical