Interactions between a PCMH and a PCMH Neighbor

The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices

This position paper by the American College of Physicians, published in 2010, addresses how Patient Centered Medical Home (PCMH) organizations interface with specialty/subspecialty practices. This paper posits that the specialty/subspecialty practice should be a PCMH Neighbor (PCMH-N). The concept of a PCMH-N draws from the idea that the success of the PCMH model is dependent on the availability a “hospitable and high-performing medical neighborhood” that aligns their processes with the critical elements of the PCMH.

In the case of the Greater Richmond PCMH Collaborative, the PCMH-N is not limited to specialty/subspecialty medical practices. The concepts and roles of the PCMH Neighbor hold true for all organizations within the Greater Richmond patient-centered medical neighborhood. Consider the framework presented here as a way to begin thinking of your PCMH Neighbors.

“A specialty/subspecialty practice recognized as a Patient-Centered Medical Home Neighbor (PCMH-N) engages in processes that:

  • Ensure effective communication, coordination, and integration with PCMH practices in a bidirectional manner to provide high-quality and efficient care
  • Ensure appropriate and timely consultations and referrals that complement the aims of the PCMH practice
  • Ensure the efficient, appropriate, and effective flow of necessary patient and care information
  • Effectively guides determination of responsibility in co-management situations
  • Support patient-centered care, enhanced care access, and high levels of care quality and safety
  • Support the PCMH practice as the provider of whole person primary care to the patient and as having overall responsibility for ensuring the coordination and integration of the care provided by all involved physicians and other health care professionals.”

Review the types of interactions between a PCMH and PCMH-N outlined above. Consult the paper for more details and examples of care coordination agreements between a PCMH and PCMH-N.

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