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OBJECTIVES

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Objectives

  • Define the patient-centered medical home.

  • Review the rationale for the medical home model and a high-performing primary care delivery system.

  • Describe the 10 building blocks of high-performing primary care.

  • Discuss the challenges and opportunities of creating medical homes in safety-net settings.

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Mrs. C is a 58-year-old Spanish-speaking woman with poorly controlled diabetes, hypertension, and obesity. She works as a housekeeper and frequently has to miss visits with her primary care provider (PCP) because of work. Mrs. C’s PCP has a panel of 2000 patients, sees 30 patients per day, and does not speak Spanish. During her routine 15-minute visits, her PCP explores Mrs. C’s symptoms of back pain and depression using her daughter as an ad hoc interpreter, reviews her HbA1c of 9.5 and blood pressure of 160/100, and recommends dose adjustments to her medications. The PCP feels that there is not enough time to explain illnesses and treatments to Mrs. C. and worries that they do not get to preventive care. At the end of a visit, both Mrs. C and the PCP are often dissatisfied with the encounter. Despite the PCP’s best intentions and hard work, Mrs. C’s chronic conditions do not improve.

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INTRODUCTION

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Primary care in the United States is at a crossroads. With skyrocketing costs, fragmented care, limited access, and the primary care physician shortage, primary care needs to undergo substantial transformation. The patient-centered medical home (PCMH) is widely advocated as a model to address the challenges of primary care and achieve what the Institute for Healthcare Improvement calls the “triple aim”—better population health, improved patient experience, and reduced per capita costs.1

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The PCMH model aims for “comprehensive, continuous, patient-centered, team-based, and accessible primary care delivered in the context of a patient’s family and community.”2 The model first originated from the ­American Academy of Pediatrics in 1967 and was endorsed by the four main primary care professional societies in the 2007 “Joint Principles of the Patient-Centered Medical Home.”3,4 The Affordable Care Act (ACA) calls for implementation of the medical home, and multiple public and private groups have supported widespread medical home demonstration projects.5,6,7 With these efforts, the number of practices undergoing medical home transformation nationwide has grown rapidly.

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The medical home model is especially important in safety-net settings that provide primary care to underserved communities. Vulnerable populations face substantial barriers to care including limited access, low English proficiency, low health literacy, psychosocial complexity, and multiple medical comorbidities. Given its emphasis on access, whole-person orientation, team-based care, and care coordination, the PCMH model has the potential to address the many concerns of vulnerable populations.8

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Providing patients with insurance coverage and a medical home has been found to reduce racial and ethnic disparities in access and quality of preventive and chronic care and to improve outcomes for vulnerable ...

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