Patient-Centered Medical Home and Certification

by Herold Simon, MD


Doctors-On-Call is preparing to become a certified Patient-Centered Medical Home (PCMH). PCMH is a model that has been created for primary care delivery in the office visit. With a certification to be granted by the National Committee for Quality Assurance, Doctors-On-Call will bring to the patient’s home the concepts of PCMH which revolve around the patient’s clinical and non-clinical needs.

The medical home is team-based with a variety of disciplines and includes the patient and family as active members of the team. The first emphasis of PCMH is on access to care, providing, for example, same day appointments and enabling patients to receive medical advice from providers 24 hours a day/7 days a week. Timely access to medical care is very important as it has been proven to prevent unnecessary visits to the medical emergency rooms (11% over non-PCMH facility for Medicare patients) and hospital admissions.

Historically, patients are prescribed a plan of care by their provider and nurse that they are expected to follow. In the PCMH model, the patient and family are involved in the treatment plan that takes into consideration each patient’s unique needs, values, culture, language, preferences as well as limitations. Patients receive adequate education on self-management by trained staff and are encouraged to perform tasks towards specific goals.

Another component of PCMH is care coordination. The medical home coordinates the care across all elements including behavioral health, specialty care, hospitals, home health care community services and support. This is a critical element especially during transition of services. The medical home must also demonstrate commitment to quality and quality improvement by consistently utilizing evidence-based medicine and using clinical-decision support as tools to guide patients and their families in decision making.

PCMH is a model that holds promise to health care as a whole, but the homebound patients whom we serve can potentially benefit the most from that practice as they are older, sicker and more likely to end up in the emergency room or be admitted for a condition that could have been addressed early by a phone call and/or a home visit by a medical provider: physician, nurse practitioner or physician assistant.

Looking for PCMH certification is another way that Doctors-On-Call validates its dedication to continue providing good quality of care to our patients.