Medical Home

The American Academy of Family Physicians defines a medical home as one that is based on the Joint Principles of the Patient-Centered Medical Home (PCMH) and the five key functions of the Comprehensive Primary Care Plus (CPC+) initiative. These key functions are:

  1. Access and Continuity
    Medical homes optimize continuity and timely, 24/7 first contact access care supported by the medical record. Practices track continuity of care by physician or panel.

  2. Planned Care and Population Health
    Medical homes proactively assess their patients to determine their needs and provide appropriate and timely chronic and preventive care, including medication management and review. Physicians develop a personalized plan of care for high-risk patients and use team-based approaches to meet patient needs efficiently.

  3. Care Management
    Medical homes empanel and risk stratify their whole practice population and implement care management for patients with high needs. Care management has benefits for all patients, but patients with serious or multiple medical conditions benefit more significantly due to their needs for extra support to ensure they are getting the medical care and/or medications they need.

  4. Patient and Caregiver Engagement
    Medical homes engage patients and their famiilies in decision-making in all aspects of care. Such practices also integrate into their usual care both culturally competent self-management support and the use of decision aids for preference sensitive conditions.

  5. Comprehensiveness and Coordination
    Primary care is the first point of contact for many patients, and therefore is the center of patients' experiences with health care. As a result, primary care is best positioned to coordinate care across settings and among physicians in most cases. Primary care medical homes work closely with patients' other health care providers to coordinate and manage care transitions, referrals, and information exchange.

    The functions of a medical home depend on the support of enhanced and prospective accountable payments, continuous quality improvement driven by data, and optimal use of health information technology.  (May Board 2008) (March 2017 BOD)