Key Functions of a Medical Home

Patient and Caregiver Engagement

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 patient and caregiver engagement, one of the five key functions of medical homes.


Patient and Family Advisory Councils (PFAC)

Patient advisory panels (also referred to as patient advisory boards) encourage patients to become actively involved in and advocate for their health and the health of their families. This involvement strengthens the patient-provider relationship and helps a practice identify ways to improve services, decrease barriers, and increase patient satisfaction.

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Patient Self-management

Traditional patient education offers patients health information, but does not provide them with the problem-solving skills that improve the application of knowledge in real-life situations. Essentially, the patients are passive and the physician is the expert who tells the patients what to do. On the other hand, PSMS is a system of care in which the care team works collaboratively with patients, instead of just dispensing advice, writing prescriptions, and hoping that patients will comply. It shifts the care paradigm from reactive symptom management to collaborative health management, where the patient actively shares responsibility for solving problems and treatment outcomes.

In the self-management model, the patient participates in developing his or her treatment plan, which includes self-management goals the patient has suggested and is likely to achieve. The care team helps the patient develop a written action plan for accomplishing the goals, and follows up by phone to check progress and answer questions.

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AAFP TIPS™

Transform your practice with AAFP TIPS™, providing ready-to-use resources to help you make small changes that yield big results.

 

The Medical Home Checklist

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

Motivational Interviewing

Motivational interviewing (MI) is patient-centered, goal-oriented counseling to motivate behavior change. Originally developed for use by substance abuse counselors, MI also works well in family medicine practices and other health care settings. Care team members can use MI techniques to encourage patients to adopt healthy behavior changes aimed at achieving specific goals, such as weight loss, smoking cessation, or medication adherence. Learn about the principles of MI, and how train staff on its use.

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Patient Surveys/Focus Groups

In a family medicine practice, it is imperative to conduct research to understand your patient population and the services they value. Keeping up with trends will allow you to maintain a competitive edge as the health care landscape changes. Focus groups can provide your practice a valuable understanding of what your patients think about the services they receive.  Additionally, they can help you determine whether there is a business case for implementing a new service or program, and provide an indication of how patients will respond. Use the steps below to inform the development of focus groups in your practice.

Patients have valuable insight into the quality and process of care you provide. Real-time feedback informs quality improvement activities and helps ensure that you are effectively improving your patients’ experiences and providing them with the care and services they need.

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Shared Decision Making

Shared decision making (SDM) is a process that engages patients in actively working with their physicians to make health care decisions. SDM seeks to inform patients about their health conditions and the benefits and risks of potential treatment options so they can collaborate with the members of their care team to create individualized care plans. The SDM models currently being developed and tested by several organizations build upon and formalize the decision-making processes that some physicians already use with patients. Learn about the different evidence-based approaches to SDM to better evaluate what works best for your practice and your patient population.

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Patient Home Monitoring for Chronic Conditions

Home monitoring helps patients who have chronic conditions, such as diabetes and hypertension, to better track and understand their medical conditions. But the results of home monitoring are useful only if the patient knows how to accurately collect data and how to act on the information he or she gathers. Develop a workflow and create or collect resources to help your care team members inform and support patients’ home-monitoring efforts.  

AAFP TIPS™

Transform your practice with AAFP TIPS™, providing ready-to-use resources to help you make small changes that yield big results.