This includes care for all stages of life, acute care, chronic care, preventive services, and end of
life care.
Care is coordinated and/or integrated – across all elements of the complex health care system
(e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient‘s
community (e.g., family, public and private community-based services). Care is facilitated by
registries, information technology, health information exchange and other means to assure that
patients get the indicated care when and where they need and want it in a culturally and
linguistically appropriate manner.
Quality and safety are hallmarks of the medical home.
Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a
compassionate, robust partnership between physicians, patients, and the patient‘s
family.
Evidence-based medicine and clinical decision-support tools guide decision-making.
Physicians in the practice accept accountability for continuous quality improvement
through voluntary engagement in performance measurement and improvement.
Patients actively participate in decision-making and feedback is sought to ensure
patients‘ expectations are being met.
Information technology is utilized appropriately to support optimal patient care,
performance measurement, patient education, and enhanced communication.
Practices go through a voluntary recognition process by an appropriate nongovernmental entity to demonstrate that they have the capabilities to provide patient
centered services consistent with the medical home model.
Patients and families participate in quality improvement activities at the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded
hours, and new options for communication between patients, their personal physician, and
practice staff.
Payment appropriately recognizes the added value provided to patients who have a patient-
centered medical home. The payment structure should be based on the following framework:
It should pay for services associated with coordination of care both within a given
practice and between consultants, ancillary providers, and community resources.
It should support adoption and use of health information technology for quality
improvement.
It should support provision of enhanced communication access such as secure e-mail
and telephone consultation.
It should recognize the value of physician work associated with remote monitoring of
clinical data using technology.
