Key Functions of a Medical Home

Planned Care and Population Health

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)(3 page PDF) and the five key functions of the Comprehensive Primary Care Plus (CPC+) initiative.

Learn more about comprehensiveness and coordination, one of the five key functions of medical homes.

Population Health Management

Population health management lies at the core of the medical home model. It requires practices to regard patients as individuals and as members of a population. Doing so allows a practice to identify the pressing and pending health needs of its patient population, and determine how best to prevent or meet those needs.

Population health management involves a proactive, team-based approach to care that focuses on prevention, early intervention, and close partnerships with patients to tightly manage chronic conditions.

Population health management enables a practice to more easily:

Proactively identify patients who need evidence-based chronic or preventive care using health data collected and stored in patient registries.
Provide planned care and outreach based on patient diseases or conditions.
Provide patient self-management support.
Monitor patient progress, identify appropriate care plans, and recommend changes to care plans by including prompts in the electronic health record.
Monitor practice performance by tracking patient data and comparing it with national guidelines or internal benchmarks.

Learn More:

Population Health Curriculum (www.graham-center.org) -- Robert Graham Center

Planned Care

Planned care is a pivotal part of the Chronic Care Model, which outlines a framework for improving chronic illness care at the individual and population levels. The overarching goal of planned care is to achieve improved outcomes that result from productive interactions between a prepared practice team and an informed, activated patient. Population health management, enabled by registries, allows your practice to identify and monitor your patients’ health before they arrive at your office in an acute or crisis stage. Planned care gives you and the care team the opportunity to proactively focus on care that you may not have time to provide during an acute or more focused visit.

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