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Guide to the Patient-Centered Medical Home For Patients


What is the Patient-Centered Medical Home?  

The Patient-Centered Medical Home, also referred to as the PCMH, is a new model of health care that strengthens the physician-patient relationship by replacing episodic care with long-term, coordinated care. Every patient in a PCMH is advised to select a primary care physician who leads a team of health care providers that take responsibility for patient care. The care that patients receive through a PCMH is intended to be more personalized, coordinated, effective and efficient.

What is NCQA?

NCQA is the National Committee for Quality Assurance. NCQA is a non-governmental organization dedicated to improving the quality of health care in the US. For medical practices that meet their standards, NCQA awards them recognition as Patient-Centered Medical Homes.

What are the NCQA standards?

In general, the NCQA standards reflect NCQA’s commitment to improved access to care, affordability and accountability. NCQA emphasizes the following aspects of care: patient centeredness, continuous quality improvement, coordinated care, improvement in patient experience, evidence-based medicine, use of the electronic health record, increased attention to behavioral health, and improved chronic care management

Which health care organizations in the Pittsburgh area are involved with PCMH?

Both Highmark and UPMC are involved in initiatives to promote PCMH. As an independent practice association, Genesis Medical Associates is involved with and is cooperating with both organizations in the process of obtaining NCQA recognition for our practices.


Enhanced Access and Communication

The goal of this standard is to increase access to medical care. Improved access is accomplished by accommodating patient’s requests for same day appointments whenever possible. It also provides to access to clinical advice during office hours as well as access to a provider after office hours.

Identify and Manage Patient Populations

This standard involves the use of the electronic health record (EHR) to collect and record data in a structured format. The collected data is used, in conjunction with evidence-based guidelines, to remind physicians and patients about preventative services, chronic disease services, or issues related to specific medications.

Plan and Manage Care

This standard stresses the importance of using evidence-based guidelines for preventive, acute and chronic care. Evidence-based guidelines are systematically developed statements designed to help practitioners and patients make decisions about appropriate health care for specific problems. For clinicians, guidelines provide a summary of the relevant medical literature and offers guidance in deciding which diagnostic tests to order, which treatments to use for specific conditions and other aspects of clinical practice.

Provide Self-Care Support and Community Resources

This standard requires that each practice provides each patient with educational resources to help them with self-management of their specific disease. There are many ways to determine if a patient would benefit from self-care resources and the EHR is especially useful for this purpose. In addition, the PCMH practice provides patients with information regarding community resources for such problems as mental health, substance abuse, obesity and smoking cessation.

Track and Coordinate Care

This standard requires that each practice use the EHR to track aspects of care such as test ordering and results, referrals to specialists, transitions of care between hospitals, ER’s and nursing homes.

Measure and Improve Performance

This standard stipulates that practices measure performance data such as patient satisfaction surveys to identify ways to improve care. Each practice also looks at data that reflect how well they are performing with regard to preventive, chronic, and acute care, as well as utilization measures that affect health care costs. A commitment to continuous quality improvement is also required.  


The Physician’s Practice

Over the next year, your physician’s practice will be undergoing a process of change as it implements the PCMH standards. The goal is to transform each practice into one that is more patient centered. The transformation process may involve new scheduling and access arrangements, new efforts at coordinating care, enhanced quality improvement projects, care that is given by a team rather than an individual, and new uses of the EHR.

The Physician

The PCMH also transforms physicians and the way they provide care. The way that physicians provide care will change from a model in which the physician is authoritarian to one that embraces team-based care. The relationship between physician and patient will also shift toward one that is more of a relationship-centered partnership where both parties are working together toward mutually agreed upon goals.

The Practice Directors

Much of the responsibility for implementing PCMH lies with the individual practice directors. They meet regularly as a group and work collaboratively to implement the various standards. Working together with their physicians and office staff, the practice directors can foster a learning environment that is conducive to change.


Take an active role in your care

The most important thing you can do regarding your care is to learn as much as you can and take an active role in planning and managing your care. Ask questions and be willing to enter into a partnership with your provider and their PCMH team.

Specific things patients can do

  • Give a detailed and honest history of your entire family.
  • Give an update of any changes in your health each visit.
  • Take all medications prescribed as directed by your provider, and provide information about OTC and Herbal Medications that you are taking.
  • Keep all scheduled appointments with your provider and other specialist(s).
  • Discuss and be involved in your treatment plan with your provider, follow orders as given.
  • Call your provider first with medical problems, unless it is a medical emergency.
  • Avoid using the Emergency Room in non-emergency situations. Instead use Urgent Care Facilities, lists are available upon request.
  • Bring all discharge papers from Emergency Room and Urgent Care visits.
  • Inform your provider of all self-referred visits, or special test(s). Bring documents when available.
  • Provide personal email address for easy access and easy contact.