Bringing the Patient-Centered Medical Home into the Community

If there’s one thing to keep in mind about the patient-centered medical home as HealthITAnalytics.comconcludes its practice transformation series, it’s that the PCMH is about so much more than checking off boxes on a recognition framework or purchasing the right population health management technologies just to dazzle competitors and peers.

The patient-centered medical home is a deep, broad, and challenging commitment to improving the lives of patients in every way possible – and for PCMH providers, that means the work doesn’t stop once the patient pulls out of the parking lot.

Developing meaningful relationships and dialogues with the wider community, including public health departments, pharmacies, long-term care and home care providers, schools, behavioral healthcare providers, and workplaces, is a crucial factor for PCMH success.  “Health primarily happens outside the doctor’s office—playing out in the arenas where we live, learn, work and play. In fact, a minority of our overall health is the result of the health care we receive,” National Coordinator Karen DeSalvo, MD, MPH, MSc reminded the healthcare community last year.

Providers who are dependent on behaviors like medication adherence and chronic disease management for an increasing proportion of their revenue must understand how patients make health decisions in their daily lives and what can make it easier for them to choose the right paths.  Through a combination of health IT tools and care coordination techniques that leverage a human touch, patient-centered medical home providers can establish meaningful working relationships with the numerous organizations that impact patient health.

What are the most important aspects of a community-based population health management program, and how can the patient-centered medical home become a coordinating hub for the social dimension of quality healthcare?