Patient-Centered Medical Home

Patient-Centered Medical Home

Patient-Centered Medical Home

Patient-Centered Medical Home (PCMH) is a care delivery model whereby a patient’s treatment is coordinated through their primary care physician to support necessary care delivery that is tailored to a patient’s needs.

The objective is to have a centralized primary care setting that facilitates partnerships between individual patients, their personal physicians, and when appropriate, the patient’s family. Care is facilitated by information technology, health care registries, health information exchange and other means to support patient care needs in a convenient setting and a culturally and linguistically appropriate manner.

The Patient-Centered Medical Home care delivery model has been identified as a key element in meeting our quality and cost performance objectives. Evidence has shown that improved quality, lower costs and increased satisfaction occur when patients are aligned to a Patient-Centered Medical Home model.

Learn more from our PCMH Infographic.


In 2012, Mass General Brigham embarked on a journey to transform our network of primary care practices to the Patient-Centered Medical Home model of care. We took a phased approach, asking practices to lay the foundational tools, structure, and capacity necessary to adopt the higher functioning components. Our four key aims for patient-centered care are:

  1. Enhanced patient experience of care
  2. Improved health of the population we serve
  3. Reduced health care costs
  4. Improved work life of health care providers and staff
Supporting Our Practices

How Population Health Supports our Primary Care Practices Our team supports existing and new practices with developing Medical Home proficiencies in:

  • Managing patient populations
  • Process improvement training
  • New staff and leadership skill development

Centralized support services:

  • Practice Redesign & Organization
  • Epic Support/Training with PCMH Workflows (Workflow Optimization)
  • Quality Improvement (QI) Collaborative

Maintenance support and monitoring of PCMH expectations Support Integration of Population Health programs into primary care

Preliminary Certification Standards

From 2012 through 2018, the Mass General Brigham system set goals directed toward these four aims for all primary care practices. As our practices met these goals, they achieved “Primed Status,” an internal term used to identify the implementation of “building blocks” or metrics used to prepare for PCMH Recognition from the National Committee for Quality Assurance (NCQA). NCQA an independent, non-profit organization that works to improve health care quality through the administration of evidence-based standards, measures, programs, and accreditation. PCMH Recognition is based on six Medical Home concepts:

  • Team-Based Care
  • Building Patient Relationships
  • Patient-Centered Access and Continuity
  • Care Management
  • Care Coordination
  • Performance Measurement and Quality Improvement
Looking Ahead: New Standards for Advanced Primary Care

As our PCMH practices mature, Population Health has shifted from Primed Status certification to further advance our primary care goals. Beginning in 2019, Mass General Brigham primary care practices will no longer be required to pursue Patient Centered Medical Home recognition from National Committee for Quality Assurance (NCQA). By the end of 2018, 97% of our care teams will work in a NCQA recognized Patient Centered Medical Home. With this foundation in place, the Mass General Brigham system has an opportunity to sustain and optimize essential components of the Patient Centered Medical Home model. We will now be able to establish flexibility to support local initiatives where needs are greatest. The Population Health team and Primary Care offices will further refine and build upon:

  • Patient-Centered Access
  • Integrated Care
  • Engaged patients
  • Safe and High Quality Care
  • Smarter Spending
  • A Vital Workforce
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