Patient-centered medical home: Making care coordination work for your practice

The centerpiece of the patient-centered medical home (PCMH) model is a multi-disciplinary team that has everyone working at the top of their license to provide the right care, at the right time, in the most appropriate setting. But the success of a PCMH relies on a practice’s ability to track the care patients receive across the various components of the medical home using care coordinators and technology.

Judith Steinberg, MD, MPH, recently had a male patient who was diagnosed with AIDS. Making matters worse, his wife was found to be HIV-positive. The couple was overwhelmed and scared as their nightmare unfolded in the exam room. After discussing both diagnoses with the couple, Steinberg opened the exam room door, a behavioral health specialist stepped in, and counseling started immediately.

The case became more complicated when a cancer diagnosis was later added to the male’s list of problems. As his care plan was put into action, Steinberg was always aware of his health status even as he moved between inpatient, outpatient and specialty care settings because a care coordinator was in charge of making sure all the information made it into his record.

How the case was handled is a textbook example of what a PCMH is, says Steinberg, deputy chief medical officer for UMass Medical School’s Commonwealth Medicine division, which participated in a multi-payer PCMH demonstration project that ended on March 31.

“When I describe the patient-centered medical home to practices, providers, or to anyone—all of us are patients at one point or another—I like to say it’s really the way we, as patients, would like to see our care delivered,” says Steinberg.