Primary care physician who coordinates medical home

Future of the medical home

By Liz Kwo, MD, MBA, MPH - Chief Medical Officer, Everly Health. To give you technically accurate, evidence-based information, content published on the Everlywell blog is reviewed by credentialed professionals with expertise in medical and bioscience fields.

Table of contents

Patient-centered medical home (PCMH) also known as medical home is a model of primary care coordinated by a physician or a care team, often consisting of a nurse, medical assistant, behavioral health specialist and physician. The model provides high quality care, better health outcomes, and decreases healthcare costs and many states have focused on PCMHs.

Why is the medical home model necessary?

Usually, patients affected by more than one health issue must see several medical specialists and undergo various medical procedures or lab investigations. The communication between these medical specialists can sometimes be delayed or duplicated. Aside from the obvious issues for the patient (who needs to undergo the lab investigations all over again or to wait a long time for results to be communicated), repeated medical procedures or investigations imply also more time allocated by the medical specialists to the same patient and increased costs for repeating these procedures or investigations.

Medical home changes all that: the entire healthcare of a patient is coordinated by a single primary care physician (or care team) who designs an appropriate care plan based on the diseases, the medical investigations, at-home lab tests, procedures and health results of that patient. Research indicates that medical home model leads to a decrease of healthcare costs resulting from fewer visits to ER, from less avoidable hospital admissions and less utilization of medical services and medical staff’s time.

Major milestones in establishing today’s medical home model

The term "medical home" has been introduced by the American Academy of Pediatrics in 1967 and it was used to describe a source for all medical information about a child. In 1992, the same institution issued a policy statement in which the medical home was defined as a strategy needed to deliver a coordinated, continuous, comprehensive and family-focused care for all children.

2001 marked the publishing of “Crossing the Quality Chasm” by the Institute of Medicine (currently National Academy of Medicine), a crucial report that highlighted the quality gaps from the American healthcare system and that projected a care focused, in the future, on the patient.

The next year, seven national family medicine organizations released the project “Future of Family Medicine” which recommended (among other things) a "personal medical home" for each American, allowing them to receive preventive, chronic and acute health services.

The project was used in 2004 for a review that identified a link between medical home and improved health outcomes, lower health costs and decreased health differences between the “more socially advantaged populations and socially disadvantaged subpopulations”.

An "advanced medical home" model was developed in 2005 by the American College of Physicians. The model involved support tools for clinical decisions, improved and handy access to care, indicators to measure the quality of care provided, information technology adjusted to healthcare, as well as tools for collecting feedback regarding the model’s performance.

The model addressed also the need to reform the existing payment system. The medical home model began to be intensively promoted in 2006 once the Patient-Centered Primary Care Collaborative was created as a partnership between several organizations, employers, primary care societies, national health plans, patients’ groups and IBM. A year later, in 2007, the Joint Principles of the Patient-Centered Medical Home were released by the American College of Physicians (AAFP), American Academy of Family Physicians (AAFP), American Osteopathic Association (AOA) and American Academy of Pediatrics (AAP).

According to these principles, the medical home care is:

  • Patient-centered: medical home model assists patients in learning how to manage their care, also involving the patient’s family and caregivers in these care plans. PCMH also engages through various initiatives the patient in getting involved in policies aimed at improving health outcomes.
  • Accessible: the PCMH delivers 24/7 electronic or telephone access to medical services, decreases the patients’ waiting times and eases the communication between patient and primary care physician through the use of information technology.
  • Coordinated: the PCMH makes the primary care physician the coordinator of all healthcare information and services needed by a patient, including specialty procedures, hospitalizations or lab investigations.
  • Comprehensive: in the medical home model, a team of caregivers is appointed to monitor and manage all the physical and behavioral health needs of a patient from prevention and wellness to diagnose and treatment of acute and chronic medical affections.
  • Committed to Quality and Safety: medical home model uses health information technology (HIT) and other technology tools to support patients in making the best decisions regarding their health.

What is the future of medical home?

In 2016, Patient-Centered Primary Care Collaborative released a review that showed PMCH saves money by reducing the visits to ERs, the hospitalizations and re-hospitalizations and the utilization of other healthcare products and services.

A research published in February 2021 compared PCMH model with the traditional care model in the Federally Qualified Health Centers (FQHC) and indicated an estimated of $1.05 billion cost-saving impact of PCMH in 2014 across all FQHCs.

Medical home programs implemented at state level showed a common result: PCMH generates cost savings in various medical specialties, in treating different illnesses and in providing better health outcomes for patients from different social backgrounds. But medical home model still has lots of things to sort out. PCMH is not a fit-for-all model, as the practices are different even though the goals are similar.

A study conducted between 2015 and 2016 on twenty Patient-Centered Primary Care Home Programs from Oregon concluded that understanding the local context in which these programs operated was a key factor in implementing the medical home model. Although the clinics participating in the study differ in size, geography, practice specialty, population, standards and metrics, they all faced the same type of challenges in implementing PCMH: untrained staff, complex healthcare environment, scarce financial incentives, obstacles in adjusting the organizational strategy, information technology issues.

To address these challenges, decision-making authorities and organizations need to grant now and in the future actual support by providing clinics with the tools they need in order adopt the medical home model. Trainings for employees, financial incentives for the primary care physicians or technical assistance are among the tools that can smooth the path to becoming PCMHs.

In other cases, low investment in primary care is the main cause for which PCMH is not achieving its targets, especially the cost savings ones. The 5 to 8% budget allocated to primary care in the U.S. is less than needed and the percentage dedicated to supporting practices in becoming PMCHs and in covering the costs derived from sustaining the medical home model, as well as the reimbursement for operating in this model is even less sufficient. Higher investments in primary care and in PCMH are the obvious and (in some cases) the long awaited solution.

The medical home model of the future is one that needs also strong support from the states in which it has been or will be implemented. States have to provide relevant information to support the expansion of the PCMHs and to attract more involvement from payers.

Financial sustainability is one of the most relevant elements in the eyes of the payers and states must build data infrastructures needed to sustain medical home programs. Moreover, payers are encouraged to provide or to continue to provide support for these programs as long as they receive quantifiable and reliable results.

In addition, PCMHs must be able to serve different needs of various populations by developing processes for each of them, as adjusting being the key in operating under Medicaid or Medicare plans all over the country. Partnerships between states and federal government is another tool that PCMH can use in accessing public or private funding in order to continue or expand their activity.

The future medical home model needs to operate in a less fragmented payment system. Different payers have different requirements for accepting claims from PCMHs and that creates financials risks, confusion and tension on the primary care physicians and care teams. Standardization of requirements in accepting and handling claims is a step that payers will have to take in order to help establish an environment of predictable payment with the alignment of performance metrics and costs being also unavoidable.


Medical home model is generating important and positive changes in the quality and cost of patients’ healthcare. Although the model is no longer new, challenges still need to be addressed with methods and strategies adjusted to contextual conditions of each practice, clinic and region. With 1 in 5 primary physicians currently recognized by the National Committee for Quality Assurance (NCQA) as participants in existing PCMH programs, more advanced models are expected to be designed with an increased reliance on analytic and information technology tools to maintain or increase the focus on the patient.

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