Local governments can invest in this strategy using State and Local Fiscal Recovery Funds (SLFRF) from the American Rescue Plan Act (ARPA).
- This strategy can help improve access to health services. The U.S. Department of Treasury has indicated that strategies that help achieve this outcome are eligible for the use of Fiscal Recovery Funds.
- Investments in this strategy are SLFRF-eligible as long as they are made in qualified census tracts or are designed to assist populations or communities disproportionately impacted by COVID-19.
Program overview
Providing a patient-centered approach to health care: The Patient-Centered Medical Home (PCMH) is an approach to delivering primary care services that is coordinated, team-based, culturally appropriate, and patient-centered. This model has been shown to improve health care access and utilization and reduce hospital visits.
Offering comprehensive and coordinated care: The PCMH model integrates care across a range of specialties, providing a wider range of services than a traditional model. In addition to general primary care services, patients can access pharmacists, dieticians, mental health professionals, and other providers through their primary care team. When patients need specialized care, the primary care team coordinates services with other providers across the same healthcare system.
Increasing accessibility and patient involvement: When receiving care from a PCMH primary care team, patients can expect accessible services and a culturally relevant, patient-centered experience. As part of the model, patients and their families are included in decision-making and presented with options for different intervention and treatment plans. The PCMH model also incorporates expanded hours for visits, shorter waiting times for appointments, and around-the-clock access to medical staff.
- Cost per Participant
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Not available
Multiple studies with rigorous designs demonstrate that the Patient-Centered Medical Home model is a well-supported strategy to reduce hospital visits and improve health care access, primary care utilization, and care quality.
- This assessment is based on evidence from a 2018 research synthesis.
Customize staff roles to match community needs: Practices should take advantage of the PCMH model’s flexible staffing structure to establish roles that best address a specific community’s needs. For example, if a patient community is made up largely of non-native English speakers, it may be valuable to have a full-time translator on site. Or if a community has a high prevalence of drug addiction, a practice should consider hiring a licensed counselor specializing in addiction treatment.
Utilize case managers or care coordinators: Case managers and care coordinators are part of the PCMH team, working closely with primary care providers. They can conduct home visits, provide remote or phone support, and connect patients with community services. Adding a case manager or care coordinator to a PCMH team helps ensure proactive communication, consistent monitoring of health concerns, and strong coordination across different health and social services.
Develop communication and data systems to support integration: Establishing clear communication plans with other medical providers helps to reduce the time needed for referrals. Communication systems with non-medical organizations (e.g., social workers, nonprofit organizations, schools) can help address components of patient care related to social determinants of health. Creating joint Electronic Health Record systems across multiple providers, including behavioral or mental health providers, contributes to the smooth integration of different components of care and ensures that providers have the full context when treating patients.
Identify a sustainable payment structure: The traditional fee-for-service (FFS) model for health insurance payments may not cover the cost of running a PCMH practice. Core activities, like care team meetings or care coordination, are often not reimbursed. When adopting the PCMH model, practices should identify insurance plans that reimburse for these core activities, like Medicaid; plan to cross-subsidize care from other operations; or identify grants to cover the cost of transitioning to the new model.