- Primary care providers and their teams coordinate care across the health care system, working with patients to address all of their health care needs
- Provide patients with referrals and connections to other qualified healthcare providers as needed
- Offer enhanced access, including expanded hours and easy communication options for patients
Strength of evidence
Evidence level: Proven (highest tier)
Proven (highest tier)
Ranked as having the highest level of evidence in the County Health Rankings and Roadmaps "What Works for Health" clearinghouse
Outcomes and impact
- Improved quality of preventative care through continuity of care
- Produce large savings with respect to medical inpatient care across hospital systems
- Reduced emergency room visits and hospital utilization.
- Reducing socio-economic disparities in preventive care screenings
- Increased patient satisfaction and patient engagement
Keys to successful implementation
- Note: This content is under review
- Patient care coordination should be at the center of medical home operations. Patient care should be coordinated across medical, social, developmental, behavioral, educational and financial needs in order to achieve optimal health and wellness outcomes for individuals.
- Programmatic success rests on adequate training across hospital systems. Medical professionals should be provided comprehensive training to perform activities related to care coordination and relationship building in order to achieve wellness outcomes.
- Programs should be family and patient centered and address the direct needs of the patients and their families. Patient centered medical homes see high rates of effectiveness across evaluations.
- Partnerships with primary care centers and hospital systems are crucial in order to set up and staff medical homes.