The PCMH model is a person centred health system designed to enhance the patient experience, improve population health, reduce health care costs and foster greater satisfaction of health providers, this is known as the quadruple aim.
The persons health is managed at home by the patient, family and carers.
In patient centred care, the patient, their families and carers are at the centre of care. Ultimately it is their values, resources and actions that are the key determinants of health outcomes.
It is at home where care is most effective and optimal differences to patient outcomes occur. It also ensures that the patient and their family and carers can access the care that is needed when and where they need it.
Patient centred care carries a notion that care coordination best happens when the patient and their family or carers are empowered, willing and able to lead their own health and care choices.
There is growing evidence that people benefit from an ongoing and consistent relationship with a trusted general practitioner.
The relationship with the GP is supported by the practice team to create the medical home team. This team can grow to include members of the broader healthcare neighbourhood as patient needs change.
Peoples needs change and increase over time. As this happens the care team expands, adding new members.
The extended team may include physiotherapists, community pharmacists, psychologists, optometrists, exercise physiologists, dietitians and other allied health professionals. It may also include community nursing, home care providers and personal care providers.
The patient is treated as an informed partner in shared care decision making and the medical home serves as a gateway to specialist care across the health system, ensuring patients can access the care they need through the most efficient pathway.
An efficient healthcare neighbourhood has access to relevant patient information and the medical home is responsible for coordinating the care and also ensuring an accurate and complete clinical record for each patient.
Patients are not transferred from one team to another, the medical home always remains a central part of their core team. As the patient’s acuity and needs increase the care team expands and as acuity diminishes or becomes better controlled the team will contract.
Creating services that sit outside the existing relationships have the potential to disrupt the system resulting in worse health outcomes. Therefore the most efficient and effective way to improve the system is by placing resources as close to the centre of the circle as possible.
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