In 2007, the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and American Osteopathic Association (AOA) developed joint principles to describe characteristics of a Patient-Centered Medical Home (PCMH). These principles include providing each patient with a personal physician who leads a team of individuals to collectively take responsibility for the care of the patients. This care is provided for all of the stages of life; acute care, chronic care, preventive services, and end of life care. The care is coordinated across the health system, including primary and specialty offices, hospitals and extended care facilities, and communities. Emphasis is placed on quality and safety, and access to care providers. Payment reform is also stressed as an important principle, to encourage compensation for quality of care, and population management.
The Agency for Healthcare Research and Quality (AHRQ) further defines the Patient-Centered Medical Home as an approach to the delivery of primary care that is patient centered, comprehensive, coordinated, accessible, and committed to quality and safety. The patient-centered approach actively supports patients in learning to manage and organize their own care. Recognizing that patients and families are core members of the care team, patient-centered practices ensure that they are fully informed partners in establishing care plans. Comprehensive care involves working with a team of providers within the clinic, to augment and enhance the care of the physician. Team members can include nurses, social worker, dieticians, or other ancillary providers.
The Department of Family Medicine is focused on creating the ideal PCMH experience. Our health centers offer patients both evening and weekend hours. We provide on-site clinical pharmacists, social workers, and dieticians. Our nurses are trained in case management and self-management support. Each site has a panel manager, to assist in population management. In 2013, all five of our clinical sites qualified for PCMH Honor Roll status through Blue Cross Blue Shield of Michigan, which is based on consistently high achievement in implementation of PCMH capabilities, and on performance on quality, use and efficiency metrics. Future initiatives include development of patient advisory committees and enhancing technologic capabilities for advanced screening and diagnosis at the site level.
Kathryn M. Harmes, M.D., PCMH Medical Director
Heather L. Holmstrom, M.D., Assistant PCMH Medical Director