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

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

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.).

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.