The Key Functions of a Medical Home

Comprehensiveness and Coordination

Practice Improvement Checklists

Ready to position your practice to better respond to the changing health care landscape? Learn how to get started. 

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 access and continuity, one of the five key functions of medical homes.

Care Transitions

The medical home should serve as the center for coordinating patient care across the medical neighborhood. Effective care coordination between primary care, specialists, subspecialists, and other health care facilities will contribute to a more professional, efficient, and safe environment for patients. If you don’t yet have them in place, a system for managing care transitions, care coordination agreements between the medical home and other specialists/subspecialists/facilities, and office protocols to support the agreements can help formalize how physicians work together.

A high-functioning medical home requires a staff person or team to guide and follow up with patients as they journey through the healthcare system. If you don’t yet have such a staff member or team in your practice, establishing one will help you oversee and track the status of referrals and consultations. Effective management of care transitions is becoming increasingly important with new models of payment and care delivery and the widespread adoption of advanced communication technology.

Practice Improvement Checklists

Ready to position your practice to better respond to the changing health care landscape? Learn how to get started. 

Community Resources Relationship Building

The medical home should provide comprehensive primary care and serve as the leader in coordinating care for patients across the medical neighborhood. Providing additional educational resources, self-management assistance, and linkages to services not available in the PCMH complements the patient-centered efforts of the medical home.

First, identify any relationships your practice already has in place. Then research what additional resources are available in your area, and note any that might be beneficial or that will help you meet your patients’ needs.

Reach out to the community resources and establish a relationship. Explain your patients’ general needs and identify a contact person at each organization. Find out what each resource can provide and document the information on a spreadsheet. Consider including the following pieces of information: hours/days of operation, associated costs, services provided, eligibility requirements, health insurance coverage for services, and contact person.

Create a notebook or document that organizes all the community resources and pertinent information and is easy for staff to access. Update the information on an annual basis to ensure you have the most current information.

Connecting Digitally to Medical Neighborhood

Participate in Health Information Exchange

Health information exchanges provide a means for health care organizations and professionals to share patient health information. The sharing of health information allows health care professionals to access and retrieve patient clinical data to provide safer, timelier, and more efficient patient care. Connecting to your local or state HIE will not only allow you to access the information you input, but will also allow you to gather medical information from other organizations to help inform your patient care decisions.

An HIE offers a partial solution to a fragmented health care system that delivers care at a high cost. HIEs provide interoperability, or a secure means for sharing patient information between hospitals, labs, specialists, and other facilities. Patient information coordinated between facilities—as facilitated by HIEs—enables a physician to have correct, updated patient information at the point of care, thereby helping to eliminate gaps and duplication in care. Additionally, HIEs can save money and staff time, as staff will spend less time scanning and faxing documents; tracking down lab, diagnostic, and referral reports; and contacting patients by phone to share health-related information.

Performance Measures to Evaluate and Improve Care Transition Processes

Performance measurement is an important tool for assessing and improving your practice and its relationships with others in the medical neighborhood. Use the performance measurement process to evaluate the efficacy, efficiency, and safety of the changes your team has implemented to improve the care transition process for patients, physicians, and staff.