Patient Centered Medical Home

PCPs that join SVHP must become recognized as a Patient Centered Medical Home within two years of joining.

What is Patient Centered Medical Home? 

It is an approach to providing comprehensive medical care which will allow better access to health care, increase patient satisfaction and improve health.  PCMH facilitates partnerships between the patient, their primary care physician and in some instances, family members.  Use of information technology and the health information exchange helps to assure the patient gets the appropriate care when and where they need it.

Read More:

NCQA PCMH Recognition 

The Impact of Primary Care Practice Transformation on Cost, Quality, and Utilization

Improved Outcomes Associated with Patient-Center Medical Homes


Personal physician: each patient has an ongoing relationship with a personal physician trained to provide first contact, and continuous and comprehensive care.

Physician directed medical practice: the personal physician leads a team of individuals who collectively take responsibility for the ongoing care of each patient.

Whole person orientation: the personal physician is responsible for providing all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care; chronic care; preventive services; and end of life care.

Care is coordinated and/or integrated: care is coordinated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Quality and safety is ensured through the following:

  • Practices advocate for their patients to support the attainment of optimal, patient-centered outcomes that are defined by a care planning process driven by a compassionate, robust partnership between physicians, patients, and the patient’s family.
  • Evidence-based medicine and clinical decision-support tools guide decision making
  • Physicians are accountable for continuous quality improvement through voluntary engagement in performance measurement and improvement.
  • Patients actively participate in decision-making and feedback is sought to ensure patients’ expectations are being met
  • Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication
  • Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services consistent with the medical home model.
  • Patients and families participate in quality improvement activities at the practice level.

Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.

Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:

  • Reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
  • Pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
  • Support adoption and use of health information technology for quality improvement;
  • Support provision of enhanced communication access such as secure e-mail and telephone consultation;
  • Recognize the value of physician work associated with remote monitoring of clinical data using technology.
  • Allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
  • Recognize case mix differences in the patient population being treated within the practice.
  • Allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
  • Allow for additional payments for achieving measurable and continuous quality improvements.