An insightful blog post from the American Academy of Family Physicians' (AAFP) vice president of advocacy and practice advancement advises primary care physicians to not consider Patient Centered Medical Home (PCMH) practice redesign and PCMH recognition as synonymous.

He encourages "every family physician to transform your practice based on the principles of the PCMH," and to "consider third-party PCMH designation if that is beneficial to your practice" and "if it is supported by a business case in your practice or local market, meaning there are payment incentives available."

He writes that PCMH should be focused on "process improvement, quality improvement, team-based and patient-centric care, and reform at a pace that benefits your patients and your practice," not on "a collection of chart extractions, screen captures, and checklists."

He recommends the AAFP's PCMH Planner as a tool to help practices move toward a medical home. PA SPREAD also has a variety of resources available to assist in PCMH advancement.

Practice-Based Care Coordination Proves Valuable for 

Patient, Providers        

One of the more daunting and expensive principles for a PCMH to meet may be coordinating care across all elements of the complex health care system.

The Agency for Healthcare Research and Quality  (AHRQ) says care coordination "involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient's care [including the patient] to achieve safer and more effective care." As such, AHRQ says the two fundamental goals of care coordination are to transfer information and establish accountability.

Care coordinators typically offer the following types of assistance:

• Answer phone calls from patients/families and assess/address needs.
• Develop and implement care plans and evaluating the effectiveness of interventions.
• Manage referrals and linkages with specialists and other health care and community resources.
• Provide patient/family education.
• Link patients/families with other patients/families for support.
• Help patients/families organize and track medical information.
• Coordinate coverage issues with insurers.
• Connect with patients following hospitalizations or emergency department visits to assess needs and assure plans for follow-up care.

Sample care plans and care coordinator training resources are offered through Group Health's MacColl Institute for Healthcare Innovation, Medical Home Learning Collaborative (pediatric-focused, but easily adapted for adult care), Alberta Health Services Self-Management and Complex Care Planning Workbook, Minnesota Department of Health, Washington State Medical Home Partnerships Project, and National Transitions of Care Coalition.

It is important to note that care coordination is different from complex care management. Many patients need some level of care coordination at some point in their life, whereas complex care management is a risk-stratified approach to provide disease management and self-management support for very high-risk patients.

As such, medical assistants, trained laypersons, social workers, and others can make excellent care coordinators. Complex care managers are usually RNs.