The term medical home was first coined by the American Academy of Pediatrics (AAP) in 1967 and initially meant a central place for archiving a child’s medical record. Gradually the term broadened to include a partnership approach with families to provide primary health care that is accessible, family-centered, coordinated, comprehensive, continuous, compassionate, and culturally effective. In its 2002 policy statement, the AAP expanded the medical home concept to include these operational characteristics: accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective care.¹

In 1978 the World Health Organization (WHO) underscored the basic tenants of the medical home and emphasized the important role of primary care in its provision. The WHO declaration affirmed primary care as the key to attaining adequate health and well-being a fundamental human right. The WHO identified primary care at the center of the health system and close to home. These precepts about primary care were embraced in the 1990’s by the Institute of Medicine (IOM) which specifically mentioned medical home.²

The IOM reports influenced the specialty of Family Medicine, and the term ‘Medical Home’ began to appear in the family medicine literature. The IOM described medical homes in the context of “continuous healing relationships” in which the patient’s needs and values are central.³ The value of continuous healing relationships between patients and physicians is not only related to patient’s perceptions but to the quality of care they receive as well.⁴ The ability of primary care to create sustained clinician-patient partnerships and provide whole-person oriented care is already eroding according to Medicare beneficiaries.⁵ Without financing for electronic medical records that specifically supports the integration care for people with chronic diseases into primary care, and that support sustained integrative relationships, patients’ experiences in the fragmented healthcare system are likely to grow worse, particularly for people with multiple conditions.⁶

In 2002, family medicine undertook a study to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. The result was “The Future of Family Medicine: A Collaborative Project of the Family Medicine Community”. The Future of Family Medicine Project states that every American should have a Personal Medical Home that serves as the focal point through which all individuals—regardless of age, sex, race, or socioeconomic status receive acute, chronic, and preventive medical care services as needed.⁷

The Chronic Care Model was another important contributor to the patient-centered Medical Home (PCMH). The elements of this model have been shown to improve the quality and cost-effectiveness of care for patients with chronic diseases.⁸ In 2004, the American Academy of Family Physicians (AAFP) used the elements of the model to describe how it might apply more broadly to models of primary care, and needed changes in how care is paid for to sustain it.⁹ This model also contributed to thinking about new models of care that can commit to becoming a PCMH, particularly those that will care for patients with complex and chronic conditions. These important efforts and studies have identified the core features that need to be present in a Patient Centered PCMH. The American Academy of Family Physicians (AAFP) and the American College of Physicians (ACP) have since developed their own models for improving patient care called the “Medical Home” (AAFP, 2004) or “advanced PCMH” (ACP, 2006). In March 2007, four organizations, the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP) and American Osteopathic Association (AOA) developed joint principles to describe the characteristics of the patient centered PCMH. (Appendix A)

There are several definitions of the PCMH. The common themes are:

• The physician based practice focuses on the coordination of patient care according to the patient’s specific needs and medical priorities. 
• The physician communicates directly with patients and their families and integrates care across settings and practitioners.

The PCMH Workgroup relied on the following definition from the National Committee for Quality Assurance (Appendix B):

“PCMH Model for Care: A PCMH is not a house, hospital or other building and should not be confused with home-health or home-care. The PCMH is a model for care provided by physician practices that seeks to strengthen the physician-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship. Each patient has an ongoing relationship with a personal physician who leads a team that takes collective responsibility for patient care. The physician-led care team is responsible for providing all the patient’s health care needs and, when needed, arranges for appropriate care with other qualified physicians.”

A PCMH also emphasizes enhanced care through open scheduling, expanded hours and communication between patients, physicians and staff. The components of the PCMH are illustrated in the transformed diagram (Appendix C).

The PCMH model for health care delivery is designed to improve the quality of the U.S. health care system and reduce health care delivery cost. This model departs from the current fee for service system which bases physician payment on the number of patients they see and the individual services or resources they use.¹⁰ The PCMH model adds a care coordination payment to the physicians. This provides an incentive for physicians to maximize quality care, reduce costs for repetitive services, and decrease hospital admissions and emergency room visits.

References

1. Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The Medical Home. Pediatrics. 2002; 110:184-6.
2. Institute of Medicine (U.S.) and Donaldson M. Primary care: America’s health in a new era. Washington, DC. National Academy Press. 1996.
3. Inkelas M, Schuster MA, Olson LM, P, CH, Halfon N. Continuity of primary care clinician in early childhood. Pediatrics. 2004; 113(6):1917-25.
4. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care. J Fam Pract. 1997; 45(2):129-35.
5. Safran DG. Defining the future of primary care: What can we learn from patients? Ann Intern Med. 2003; 138(3):248-55.
6. Robert Graham Center. The Patient Centered Medical Home – History, Seven Core Features, Evidence and Transformational Change. November 2007 p. 6.
7. Robert Graham Center. The Patient Centered Medical Home – History, Seven Core Features, Evidence and Transformational Change. November 2007 p. 5.
8. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. 2002; 288(15):1909-14.
9. Phillips RL Jr, Green LA, Fryer GE Jr, McCann, J. Knowledge Bought Dearly. Leawood, KS: American Academy of Family Physicians, 2004. 10-24-07.
10. AARP Bulletin Today. The New Face of Health Care, April 1, 2009.