What are the features of the Medical Home?

Posted by on Jun 10, 2013 in | Comments Off on What are the features of the Medical Home?

The US Patient Centred Primary Care Collaborative identifies five key features of the Medical Home.

  • Patient-centered: A partnership among practitioners, patients, and their families ensures that decisions respect patients’ wants, needs, and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
  • Comprehensive: A team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.
  • Coordinated: Care is organized across all elements of the broader health care system, including specialty care, hospitals, home health care, community services and supports.
  • Accessible: Patients are able to access services with shorter waiting times, “after hours” care, 24/7 electronic or telephone access, and strong communication through health IT innovations.
  • Committed to quality and safety: Clinicians and staff enhance quality improvement through the use of health IT and other tools to ensure that patients and families make informed decisions about their health.

In Australia there is a long standing tradition of quality general practice. Our ACMH collaborative identifies the following eleven attributes of the Medical Home in Australia.

  • Accountability The medical home partners with a patient and their family to be responsible for their care, even when that person is not standing in front of them. It will be proactive in providing for the care needs of its population. It will assist patients to navigate the health system, and share in the informed decision making by each patient.
  • Comprehensive, whole person care A medical home will be the custodian of a person’s whole health story. It will either provide care itself, or make sure that people can access the most appropriate provider for all their health needs.
  • Continuity of Care People benefit from a long term relationship with a particular general practitioner, or another generalist primary care provider if a GP is not available,
  • Team Based Care A medical home adopts a team based approach that includes practice nurses in the role of care managers, and other allied health providers.
  • Self Management A medical home will have systems to foster self management of each person’s health
  • Patient Participation Patients will be able to participate in the design of the services that a medical home offers.
  • Accessibility A medical home will actively manage its appointment systems to improve the provision of timely routine appointments. It will have systems to provide proactive chronic disease management and preventative health care. It will be accessible for patients with acute care needs when required, and will either provide after hours acute care or have clear arrangements in place for its patients to access after hours care.
  • Excellent Clinical information A medical home will have a systematic approach to curating each patients medical history and will ensure that their is appropriate information available to all providers of care. It will make full use of eHealth technologies.
  • System based approach and participation in Quality Improvement A medical home will have a system based approach to make sure that each patient receives best practice care. It will participate in quality improvement initiatives to improve the care it provides.
  • Connections to the ‘medical neighbourhood’ A medical home will have good relationships with other providers in their community. It will act as a gateway to the health system. and will have developed systems to make sure that all providers in a patients care are part of an integrated care team – with clear roles, goals and communication pathways.
  • Education and Training ‘Giving back’ to the next generation of clinicians is an important role for the Medical Home, and they will participate in training health professionals – not only within their disciplines, but also in the skills needed to work in a Medical Home model.