14: Ambulatory Care & the Patient-Centered Medical Home

General Principles in Older Adults

The vast changes occurring in medicine today are most prominent in ambulatory care. With the Patient Protection and Affordable Care Act passed in 2010, and growing urgency to curtail the rising costs of health care, ambulatory care has seen rapid changes to practice. The patient-centered medical home (PCMH) is one of the most widely adopted models of ambulatory health care that has been disseminated across the United States in recent years. The Centers for Medicare and Medicaid Services and the Veterans Affairs (VA), have both been implementing PCMH models at community health centers and VA medical centers around the country; private insurers and health plans are also redesigning their practices into PCMH models.

Why is PCMH being so strongly promoted as the ideal model of ambulatory care? PCMH is an approach to providing comprehensive, cost-effective primary care for patients of all ages. It aims to improve the delivery and experience of care for patients and clinicians through team-based coordinated care rather than the more ubiquitous fragmented health care norm that most patients have experienced for decades. Geriatric medicine is particularly well-suited to the PCMH approach to care because the principles of geriatrics ambulatory care (such as strong patient–provider relationships that recognize the role of family and caregivers, interprofessional team-based care, and continuous care throughout life stages and health care settings) are aligned with PCMH principles. Additionally, geriatrics-trained providers have specific skills that apply to many of the processes that comprise PCMH care.

Originally described by the American Academy of Pediatrics (AAP) in 1967, PCMH was adapted to patients of all ages by the American Academy of Family Physicians (AAFP, 2004) and the American College of Physicians (ACP, 2006), prior to a joint statement of principles in 2007 by AAP, AAFP, ACP, and the American Osteopathic Association. To date, 19 additional physician organizations support the PCMH model of care. PCMH aims to organize all care around the patient through an interprofessional team led by the patient’s personal physician, with coordination and health tracking longitudinally over time to provide best outcomes. The National Committee for Quality Assurance is the organization that lays out specific standards for practices seeking to develop into and be recognized as a PCMH.

There are 7 core principles of PCMH of which the first 6 are aligned with geriatric medicine principles. The seventh principle, on appropriate payment systems to recognize the value of care provided by a PCMH, is also one that those caring for older adults are unified behind. This chapter highlights the shared goals between geriatrics ambulatory care and the first 6 PCMH principles to demonstrate ways in which both geriatric medicine values and the PCMH model of care can enhance the care of older adults.

Personal Physician

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