PCMH Principles
For an individual, the PCMH model provides a regular source of primary care, which is associated with better health outcomes at lower costs. But, the PCMH model will also improve the patient experience. For example, patients enjoy enhanced access to care through open scheduling, expanded hours and new options for communication between patients, their personal physician and practice staff.
PCMH Benefits - Better health outcomes A regular source of preventive and primary care is associated with: Lower per person costs Lower emergency room utilization Fewer hospital admissions Fewer unnecessary tests and procedures Less illness and injury Higher patient satisfaction
Kansas’ primary care physicians organizations and health-related foundations are looking at ways to help providers implement this important and new model: the Patient Centered Medical Home.
State Law Defines the Kansas Patient Centered Medical Home The definition of a medical home according to Kansas law (K.S.A. 75-7429) is: “A health care delivery model in which a patient establishes an ongoing relationship with a physician or other personal care provider in a physician-directed team, to provide comprehensive, accessible and continuous evidence-based primary and preventive care, and to coordinate the patient’s health care needs across the health care system in order to improve quality and health outcomes in a cost effective manner.”
What is a Patient Centered Medical Home?
There are many models of a Patient Centered Medical Home. The specific model the Ks PCMH Initiative is pursuing is by TransforMED, a partner in the initiative that is a subsidiary of AAFP.
The center of the PCMH is a continuous relationship with a personal physician coordinating care for both wellness and illness. It includes:
Access to Care & Information • Same-day appointments • After-hours access coverage • Accessible patient and lab information • Online patient services • Electronic visits • Group visits • Culturally sensitive care
Practice Management • Disciplined financial management • Revenue enhancement • Cost-Benefit decision-making • Optimized coding & billing • Personnel/HR management • Facilities management • Optimized office design/redesign • Change management
Practice-Based Services • Comprehensive care for both acute & chronic conditions • Prevention screening and services • Surgical procedures • Ancillary therapeutic and support services • Ancillary diagnostic services
Health Information Technology • Electronic medical record • Electronic orders and reporting • Electronic prescribing • Evidence-based decision support • Population management registry • Practice Web site • Patient portal
Care Management • Population management • Wellness promotion • Disease prevention • Chronic disease management • Patient engagement and education • Leverages automated technologies
Quality and Safety • Evidence-based best practices • Medication management • Patient satisfaction feedback • Clinical outcomes analysis • Quality improvement • Risk management • Regulatory compliance
Care Coordination • Community-based resources • Collaborative relationships • Emergency room • Hospital care • Behavioral health care • Maternity care • Specialist care • Pharmacy • Physical therapy • Case management • Care Transition
Practice-Based Team Care • Provider leadership • Shared mission and vision • Effective communication • Task designation by skill set • Nurse Practitioner / Physician Assistant • Patient participation • Family involvement options