medical home medical home the medical home, also known as the patient-centered medical home (pcmh), is a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal health outcomes. it is described in the "joint principles" (see below) as "an approach to providing comprehensive primary care for children, youth and adults." the provision of medical homes is intended to allow better access to health care, increase satisfaction with care, and improve health. the "joint principles" that popularly define a pcmh were established through the efforts of the american academy of pediatrics (aap), american academy of family physicians (aafp), american college of physicians (acp), and american osteopathic association (aoa) in 2007. care coordination is an essential component of the pcmh. care coordination requires additional resources such as health information technology and appropriately-trained staff to provide coordinated care through team-based models. additionally, payment models that compensate pcmhs for their functions devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage further coordination. history the concept of the "medical home" has evolved since the first introduction of the term by the american academy of pediatrics in 1967. at the time, it was envisioned as a central source for all the medical information about a child, especially those with special needs. efforts by calvin c.j. sia, md, a honolulu-based pediatrician, in pursuit of new approaches to improve early childhood development in hawaii in the 1980s laid the groundwork for an academy policy statement in 1992 that defined a medical home largely the way sia conceived it: a strategy for delivering the family-centered, comprehensive, continuous, and coordinated care that all infants and children deserve. in 2002, the organization expanded and operationalized the definition. in 2002, seven u.s. national family medicine organizations created the future of family medicine project to "transform and renew the specialty of family medicine." among the recommendations of the project was that every american should have a "personal medical home" through which they could receive acute, chronic, and preventive health services. these services should be "accessible, accountable, comprehensive, integrated, patient-centered, safe, scientifically valid, and satisfying to both patients and their physicians." as of 2004, one study estimated that if the future of family medicine recommendations were followed (including implementation of personal medical homes), "health care costs would likely decrease by 5.6 percent, resulting in national savings of 67 billion dollars per year, with an improvement in the quality of the health care provided." a review of this assertion, published later the same year, determined that medical homes are "associated with better health,... with lower overall costs of care and with reductions in disparities in health." by 2005, the american college of physicians had developed an "advanced medical home" model. this model involved the use of evidence-based medicine, clinical decision support tools, the chronic care model, medical care plans, "enhanced and convenient" access to care, quantitative indicators of quality, health information technology, and feedback on performance. payment reform was also recognized as important to the implementation of the model. ibm and other organizations started the patient-centered primary care collaborative in 2006 to promote the medical home model. as of 2009, its membership included "some 500 large employers, insurers, consumer groups, and doctors". in 2007, the american academy of family physicians, american academy of pediatrics, american college of physicians, and american osteopathic association—the largest primary care physician organizations in the united states—released the joint principles of the patient-centered medical home. defining principles included: personal physician: "each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care." physician directed medical practice: "the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients." whole person orientation: "the personal physician is responsible for providing for all the patient's health care needs or taking responsibility for appropriately arranging care with other qualified professionals." care is coordinated and/or integrated: care is coordinated and/or integrated between complex health care systems, for example, across specialists, hospitals, home health agencies, and nursing homes, and also includes the patient's loved ones and community-based services. this goal can be attained though the utilization of registries, health information technology, and exchanges, ensuring patients receive culturally and linguistically appropriate care. quality and safety: partnerships between the patient, physicians, and their family are an integral part of the medical home. practices are encouraged to advocate for their patients and provide compassionate quality, patient-centered care. guide decision-making rooted in evidence-based medicine and with the use of decision-support tools. physicians' voluntary engagement in performance measurements to continuously gauge quality improvement. patients are involved in decision-making and provide feedback to determine if their expectations are met. utilization of informational technology to ensure optimal patient care, performance measurement, patient education, and enhanced communication at the practice level, patients and their families participate in quality improvement activities. enhanced access to care is available through open scheduling, extended hours and new options for patient communication. payment must "appropriately recognize the added value provided to patients who have a patient-centered medical home." payment should reflect the time physician and non-physician staff spend doing patient-centered care management work outside the face-to-face visit. services involved with coordination of care should be paid for. it should support measurement of quality and efficiency with the use and adoption of health information technology. enhanced communication should be supported. it should value the time physicians spend using technology for the monitoring of clinical data. payments for care management services should not result in deduction in payments for face-to-face service. payment "should recognize case mix differences in the patient population being treated within the practice." it should allow physicians to share in the savings from reduced hospitalizations. it should allow for additional compensation for achieving measurable and continuous quality improvements. a survey of 3,535 u.s. adults released in 2007 found that 27 percent of the respondents reported having "four indicators of a medical home." furthermore, having a medical home was associated with better access to care, more preventive screenings, higher quality of care, and fewer racial and ethnic disparities. important developments concerning medical homes between 2008 and 2010 included: the accreditation association for ambulatory health care (aaahc) began accrediting medical homes in 2009, and is the only accrediting body to conduct on-site survey for organizations seeking medical home accreditation. the national committee for quality assurance released physician practice connections–patient-centered medical home (ppc-pcmh), a set of voluntary standards for the recognition of physician practices as medical homes. in answering a 2008 survey from the american academy of family physicians, then-presidential candidate barack obama wrote "i support the concept of a patient-centered medical home" and that, as president, he would "encourage and provide appropriate payment for providers who implement the medical home model." the new england journal of medicine published recommendations for the success of medical homes that included increased sharing of information across health care providers, the broadening of performance measures, and the establishment of payment systems that share savings with the physicians involved. guidance for patients and providers on operationalizing the "joint principles" was made available. the american medical association expressed support for the "joint principles." a coalition of "consumer, labor, and health care advocacy groups" released nine principles that "allow for evaluation of the medical home concept from a patient perspective." initial findings of a medical home national demonstration project of the american academy of family physicians were made available in 2009. a final report on the project, which began in 2006 at 36 sites, was also published in 2010. by 2009, 20 bills in 10 states were introduced to promote medical homes. in 2010, seven key health information technology domains were identified as necessary for the success of the pcmh model: telehealth, measurement of quality and efficiency, care transitions, personal health records, and, most important, registries, team care, and clinical decision support for chronic diseases. accreditation the accreditation association for ambulatory health care (aaahc) in 2009 introduced the first accreditation program for medical homes to include an onsite survey. unlike other quality assessment programs for medical homes, aaahc accreditation also mandates that pcmhs meet the core standards required of all ambulatory organizations seeking aaahc accreditation. aaahc standards assess pcmh providers from the perspective of the patient. the onsite survey is conducted by surveyors who are qualified professionals – physicians, registered nurses, administrators and others – who have first-hand experience with ambulatory health care organizations. the onsite survey process gives them an opportunity to directly observe the quality of patient care and the facilities in which it is delivered, review medical records and assess patient perceptions and satisfaction. the aaahc accreditation handbook for ambulatory health care includes a chapter specifically devoted to medical home standards, including assessment of the following characteristics: relationship, including communication, understanding and collaboration between the patient and the provider and physician-directed health care team. where appropriate the relationship between the medical home and the patient's family or other caretakers also is assessed. continuity of care, including the requirement that a significant number (more than 50 percent) of a patient's medical home visits are with the same provider/physician team. the standards also require documentation of all consultations, referrals and appointments in the clinical record; and proactively planned transitions of care (e.g. from pediatric to adult or adult to geriatric or from inpatient to outpatient to nursing home to hospice). comprehensiveness of care, including preventive and wellness care, acute injury and illness care, chronic illness management and end-of-life care. standards for the provision of appropriate patient education, self-management and community resources also are addressed. accessibility, including written policies that support patient access and routine assessment of patients' perceptions and satisfaction regarding access to the medical home. medical care must be available 24/7, 365 days a year. quality, including patient care that is physician directed, the use and periodic assessment of evidence based guidelines and performance measures in delivering clinical services, and ongoing quality improvement activities. in addition, electronic data management must be continually assessed as a tool for facilitating the accreditation association medical home. aaahc medical home accreditation also requires that core standards required of all ambulatory organizations seeking aaahc accreditation be met, including: standards for rights of patients; governance; administration; quality of care; quality management and improvement; clinical records and health information; infection prevention and control, and safety; and facilities and environment. depending on the services provided, aaahc-accredited medical homes may also have to meet adjunct standards such as for anesthesia, surgical, pharmaceutical, pathology and medical laboratory, diagnostic and other imaging, and dental services, among others. certification program in addition to its accreditation program for medical homes, the aaahc is conducting a pilot "medical home certification" program, which includes an onsite survey to evaluate an organization against their standards for medical homes. full accreditation requires that organizations also be evaluated against all aaahc core standards. recognition program the national committee for quality assurance's (ncqa) "physician practice connections and patient centered medical home" (ppc-pcmh) recognition program emphasizes the systematic use of patient-centered, coordinated care management processes. it is an extension of the physician practice connections recognition program, which was initiated in 2003 with support from organizations such as the robert wood johnson foundation, the commonwealth fund and bridges to excellence. the ppc-pcmh enhances the quality of patient care through the well known and empirically validated wagner chronic care model, which encourages the health care system to use community resources to effectively care for patients with chronic illnesses through productive interactions between activated patients and a prepared practice team. furthermore, it recognizes practices that successfully use systematic processes and technology leading to improved quality of patient care. with the guidance from the acp, the aafp, the aap and the aoa the ncqa launched ppc-pcmh and based the program on the medical home joint principles developed by these organizations. if practices achieve ncqa's pcmh recognition they can take advantage of financial incentives that health plans, employers, federal and state-sponsored pilot programs offer and they may qualify for additional bonuses or payments. in order to attain ppc-pcmh recognition, specific elements must be met. included in the standards are ten "must-pass" elements: element 1a—access and communication processes the practice has written processes for scheduling appointments and