Lessons from the Community-Centered Health Home Demonstration Project: Patient-Centered Medical Homes Can Improve Health Conditions in Their Surrounding Communities

The latest challenge for health care is to improve population health and well-being while continuing to care for individuals. In the United States, good health depends more on living conditions and work environment than on access to medical services. However, only recently has the health care system made population health and health promotion a priority. This historic shift in the system is in response to incentives within the Affordable Care Act to meet its triple aim: improving quality of care and patient satisfaction, improving the health of populations, and reducing the per capita cost of health care.

Local and state health partnership models, such as accountable care organizations and accountable communities for health, are being tested, and large health care organizations are embracing a “health in all policies” approach, which emphasizes multisector collaboration to improve population health. These innovations are encouraging, but there are no concrete strategies for how primary care clinics, and safety-net clinics in particular, can participate in this larger effort. We propose that the medical home model — a system of primary care designed to meet the needs of individual patients by delivering coordinated and accessible services — offers a ready framework for community clinics to offer primary prevention to individuals and to improve health at the population level.

Five safety-net clinics in 4 US Gulf Coast states (Louisiana, Mississippi, Alabama, and Florida) are participating in the Community Centered Health Home Demonstration Project, directed by the Louisiana Public Health Institute, to expand from a patient-centered medical home (PCMH) to what is being called a community-centered health home (CCHH). The CCHH model provides a framework for primary care – and health care organizations in general – to address individual health needs while systematically addressing community conditions that affect individual health. This article describes the experience of clinics in the Gulf Coast states in creating a CCHH by building on the 3 established characteristics of a successful PCMH: 1) an explicit vision for how to serve a population, 2) engaged and visible leaders, and 3) effective clinical teams.