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Primary Care for the 21st Century: About the PCMH
Patient-centered care offers a full array of health care services using a team-based approach. This includes delivering care for all stages and ages of life, acute care, chronic care, behavioral and mental health care, preventive services, and end-of-life care. It also includes coordinating and/or integrating care for services not provided by the PCMH across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient community (e.g., family, public, and private community-based services).19
In short, the PCMH model is a win-win for the patient because it:
- Implements patient- and family-centered care based on the needs and preference of patients, families, and caregivers;
- Incorporates shared decision making;
- Encourages and supports self-management and self-care techniques;
- Facilitates complete and accurate information sharing and effective communication;
- Encourages active collaboration of patients/families in the design and implementation of care delivery;
- Ensures cultural and linguistic competency among clinicians and staff; and
- Collects and acts upon patient, family, and caregiver experience and satisfaction data.20
The PCMH Team. Health professionals share a common goal of providing high-quality, patient-centered, and team-based care that improves the health status of those they serve. The reorganization of care to a PCMH model puts primary care in the center of the health care system with doctors, nurse practitioners, physician assistants, nurses, and other health care professionals working side by side to care for patients. It draws on a team and uses the specific training and strengths of each member. For example, family physicians are trained to make complex diagnoses, often when a patient presents confusing symptoms. Nurse practitioners, on the other hand, are specifically trained to follow through on the treatment of a patient after a diagnosis and to implement protocols for chronic disease management.
Leadership is required in a medical home just as it is required in businesses, governments, schools, athletics, and other organizations. Just as every American
should have a primary care doctor, every medical home must have a physician serving as a leader who brings the highest level of training and preparation to guide the integrated, multi-disciplinary team. Delivering on this promise of a PCMH means it will be increasingly difficult for a health care professional to work alone. With each professional playing his or her specific role, the interdisciplinary PCMH team can deliver the highest quality care with the greatest cost-effectiveness. But a patient-centered team approach is the key.
Next: Meeting the Country’s Need for Primary Care Physicians