NUR 621 What is a patient-centered medical home (PCMH)?

NUR 621 What is a patient-centered medical home (PCMH)?

NUR 621 What is a patient-centered medical home (PCMH)?

According to the Centers for Disease Control and Prevention (CDC), patient-centered medical home revolves around patient care. The delivery of care should be high-quality, profitable primary care, patient focused, culturally appropriate, with an interdisciplinary approach where healthcare is managed and coordinated throughout the healthcare system (CDC, 2021). Patient-Centered care is very important to the population because it improves the health outcomes of the individuals in those communities. A healthcare system that involves the patient’s input, beliefs, culture, and values is a system that can create a mission and values that is more aligned with the patient’s goals. Within this model the healthcare organization is providing a system of transparency, collaborative, coordinated, and fast delivery of information. It values the patient’s opinions, emotional well-being, and incorporates patient and family decisions in the overall care of the patient. Healthcare providers will also be able to reap all the benefits from providing this type of care when patients respond with improved patient satisfaction scores.

Healthcare organizations must be able to keep up with the demands of community, payment reimbursement, and patient centered quality care to be able to stay in the game. Currently the healthcare organization I work for is implementing the Advanced Medical Care at Home (AMCAH) Model. The model mirrors the Patient-Centered Medical Home Model where it is patient centered, cost efficient, culturally appropriate, and uses a team-based approach. The care is delivered is an alternative to hospital-level care that is being delivered at the comfort and convenience of the patient’s home. Patients will benefit from receiving care in their home by the support they receive from their loved ones, home surroundings, and pets where that could not be possible in a hospital setting. Some of the conditions managed through this program will focus on cellulitis treatment, congestive heart failure, and chronic obstructive pulmonary disease. Within the 24-hour admission to the program the patient will receive and in-home visit and or/telehealth visit depending on what the physician has ordered. The interdisciplinary team will be daily monitoring the patient’s progress and provide support if needed. The AMCAH program will usually last 3-4 days depending on the individual’s progress and case. This program is not mandatory but voluntary. It gives patients the option to choose care at home versus staying in a hospital setting.


Centers for Disease Control and Prevention. (2021). Patient-Centered Medical Home (PCMH) Model.

Kaiser Permanente Care at Home. (n.d.). Advanced Medical Care at Home (AMCAH).

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A patient-centered medical home (PCMH) is a comprehensive health care model that utilizes a team-based approach to deliver culturally appropriate medical care through the continuum. It’s a collaborative approach that involves a primary care provider and other members of the health care team. The model is centered around the patients’ needs and interconnected with their community. Medical decisions are made by the patient in collaboration with their team members. PCMH focus on longtime care as opposed to episodic. PCMH demonstrate the value of population health (Communities Transforming, n.d.).  According to the Institute for Healthcare Improvement (2021), “population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. These groups are often geographic populations such as nations or communities, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group” (para 2).  PCMH typically perform needs assessments on their community and implement primary, secondary and tertiary prevention strategies that improve the health of the community. They facilitate connections between the patient and community-based providers and organizations (Communities Transforming, n.d.).

NUR 621 What is a patient-centered medical home (PCMH)
NUR 621 What is a patient-centered medical home (PCMH)

Communities Transforming. (n.d.) Patient-centered medical homes.

Institute for Healthcare Improvement. (2021). Population health.

The Agency for Healthcare Research and Quality (AHRQ) defines patient-centered medical homes as a team of providers that provide for patient’s comprehensive care needs from prevention, to acute and chronic care (AHRQ, n.d.). The care provided from a patient-centered medical home should be comprehensive, patient-centered, well-coordinated, highly accessible, high quality, and take into account safety. “The American College of Physicians, American Academy of Family Physicians, American Osteopathic Association, and the American Academy of Pediatrics adopted Joint Principles of the Patient-Centered Medical Home in 2007” (O’Dell, 2016). They defined it as a team led by a primary care physician that takes care of the whole person by collaborating and coordinating with all elements of the complex health care system and focusing on quality and safety with increased communication and access. It is important to population health because health care was becoming very siloed and there was and is a need to coordinate all the care through one primary team of providers. Most patients have multiple health care needs, and without coordinated care, there could be a lot of unnecessary overlap in care. When one team or physician coordinates specialties, such as cardiology, pulmonology, GI, etc, and also coordinates home health and hospitalizations, the care becomes more efficient, meaningful, and high quality. An example of this within the VA is our patient aligned care teams (PACTs). A PACT consists of a primary care physician, a nurse care manager, a clinical associate, and administrative clerk (VA, 2021). The purpose is to help coordinate care for our patients with multiple chronic medical conditions. The VA is different as it is the largest integrated health care system in the U.S.). The “integrated” part should lend to more coordinated care, but the VA is in itself very siloed. PACTs have improved that but switching over to a new EHR should make it even easier. Some of the problem comes from the veterans getting some care outside the VA and some care within. Veterans all have different service connections, so some may be 100% service connected, while others are only service connected for their hearing. This leads some veterans to only come to the VA for specific medical issues. The key is to better coordinate the care with community services and providers.


Agency for Healthcare Research and Quality (AHRQ). (n.d.). Defining the PCMH.

O’Dell M. L. (2016). What is a patient-centered medical home? Missouri medicine113(4), 301–304.

U.S. Department of Veterans Affairs (VA). (Last Updated 2021). Patient aligned care team (PACT).

A patient-centered medical home (PCMH) is a care model that helps provide quality care for patients. PCMH is an approach to deliver high-quality, cost-effective primary care with care coordination across the health system using a patient-centered, culturally appropriate team-based approach (CDC, 2021). One takeaway from PCMH for this writer is the association of the PCMH with effective chronic disease management. Chronic diseases continue to be a significant public health challenge across the USA. Data has shown that six in ten Americans live with at least one chronic disease such as cancer, stroke, diabetes, and heart disease (CDC, n.d.). The PCMH helps provide coordinated, whole-person, long-term care for individuals. According to the CDC (n.d.), PCMH defining principles are as follows:

1.     Personal physician- the patient’s contact and coordinator of care.

2.     Physician-directed medical practice- physician lead collaborative team.

3.     Whole person orientation- preventative, acute, chronic, and end-of-life services.

4.     Integrated and coordinated care- care collaboration across the healthcare system.

5.     Quality and safety- evidence-based care.

6.     Enhanced access to care- 24/7 access.

7.     Payment- value-based payment.

Some importance of the PCMH is to improve quality, reduce cost, improve patient experience, caregiver experience, and healthcare professional’s experience (AHRQ, 2013). PCMH model has made significant impacts on population health and continues to play a significant role in the healthcare system of the USA.


Agency for Healthcare Research and Quality. (2013). The medical home: What do you know, what do we need to know? A review of the earliest evidence on the effectiveness of the patient-centered medical home model.

Centers for Disease Control and Prevention. (2021). Patient-centered medical home (PCMH) model.,htm

Centers for Disease Control and Prevention. (n.d.). National center for chronic disease prevention and health promotion.

A patient-centered medical home is an approach to overall healthcare that places the patient’s needs as a priority. The patient works hand in hand with a multidisciplinary team, primarily led by the primary care medical team, to ensure the appropriate care models and practices are provided both at the correct time and in the proper setting (, 2021). An example of a patient-centered medical home practice would involve the population health and the primary care team. Patient-Centered Medical Home practice is currently used at my place of employment, which utilizes transitional care nurses, chronic care nurses, and value-based care medical assistants. These nurses fall under the population health umbrella and work remotely while providing telephonic medical and nursing services to patients in need. All three subspecialties under the primary care umbrella aim to ensure optimal healthcare at the lowest expense to the patient, enterprise, and insurance payer (, n.d). 

These nursing services are imperative to the success of a patient-centered medical home model as they ensure appropriate patient life management. These caregivers act as concierge-like patient advocates who can pend orders, close care gaps, escalate medical concerns and schedule appointments as needed for their assigned patient panels (Rundall, 2002). With patient-centered medical home models, all caregivers work cohesively, ensuring the primary care physician leads the team to meet all health and wellness needs for the patient. Without the patient-centered medical home model, population health physicians are key stakeholders to complete this level of work. 


Rojas Smith L, Ashok M, Morss Dy S, et al. Contextual Frameworks for Research on the Implementation of Complex System Interventions [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Mar. Patient-Centered Medical Home Framework.Available from:

Rundall T G, Shortell S M, Wang M C, Casalino L, Bodenheimer T, Gillies R R et al. As good as it gets? Chronic care management in nine leading US physician organizations BMJ 2002; 325 :958 doi:10.1136/bmj.325.7370.958

Cleveland Clinic Florida (n.d) Chronic care management. Retrieved from

The Patient-Centered Medical Home (PCMH) is a care delivery model whereby patient treatment is coordinated through their primary care physician to ensure they receive the necessary care when and where they need it, in a manner they can understand ( The goal is to have a centralized setting that helps partnerships between individual patients, and their personal physicians, and when proper, the patient’s family. Care is helped 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 proper manner (  

Population health refers to the health status and health outcomes within a group of people rather than considering the health of one person at a time. Patient-Centered Medical Home (PCMH) is important to Population health because the members PCP (Primary Care Physicians) coordinates their care and collaborates with other healthcare practitioners to care for the member and their family in a linguistically and culturally sensitive manner. Meeting the member where they are with realistic goals that are achievable for the member and easily supported by their family and community (