CCPEC Medical Home

What is a "Medical Home"?

We are committed to the “medical home” model of care, often called a “patient-centered medical home” (PCMH). The PCMH is a move away from the common acute-care model of treating symptoms and illness as they arise, to a broader, more team-based approach centered on a personal physician providing continuous, comprehensive, coordinated care throughout a patient's lifetime, in order to achieve maximum health improvements.

A more detailed explanation of a PCMH would include the following:

Care Is Physician-Directed

A personal physician leads a team of qualified individuals (to include additional physicians, advanced-practice nurses, physician assistants, nurses, pharmacists, social workers, educators, care coordinators, and others) who collectively take responsibility for a patient’s ongoing care. Although some PCMH medical practices are able to bring together large, diverse teams of care-providers to address patient needs, smaller practices don’t always have that same luxury, often having to build consulting relationships with providers at larger regional practices, and directly linking patients with other providers and services within their own communities.

Care Is Patient-Centered

The care team works with patients as individuals, not as collections of symptoms, taking into account each patient’s unique needs, culture, values, and preferences.

A PCMH practice encourages patients to learn to ultimately manage and organize their own care, so that patients are equipped to maintain health improvements when active care-management ends. Recognizing that not just patients, but also their families, are core members of the care team, medical-home practices work to keep those key partners fully informed in establishing, and maintaining, care plans.

Care Is Comprehensive, Focused on the Whole Person

A PCMH practice provides for the majority of a patient’s healthcare needs, or else takes responsibility for arranging appropriate care with other qualified professionals, across all stages of a patient’s life. This includes acute care, chronic care, behavioral health care, preventive services, and end-of-life care.

Care Is Coordinated, and Integrated

PCMH medical practices coordinate a broad range of care, integrating needed specialty care, hospitals, home-health care, and community and support services. This rigorous coordination is especially important during transitions between sites of care, such as when patients are being discharged from a hospital to begin at-home care.

A Short Video Explanation of the Medical-Home Approach