What is a Medical Home?

What is a Medical Home?


A person’s medical home is the general practice which they choose to be accountable for providing and coordinating their ongoing health care.

A medical home aspires to provide the highest levels of accessible, comprehensive, coordinated and person-centred care, and will have a focus on quality and safety.[1]

In a medical home, patients and their families have a continuing relationship with a particular GP,  this partnership is supported by a practice team, and other clinical services in the ‘medical neighborhood’ wrap around the patient and their families as required.


Why a Medical Home?


Our communities need high quality general practice.

General Practitioners  want to work in a system that enables them to deliver the highest standard of care to each of their patients.

The ‘person centred medical home’ is a concept that has been defined and evaluated extensively  in medical literature. It has been demonstrated to be an effective and efficient way of providing primary care –  preferred by patients and providers, improving health outcomes, and delivering better value to the community.


What are the attributes of a Medical Home?


Person Centred Care

“Recognise that we are the most important part of the care team, and that we are ultimately responsible for our overall health and wellness” [2]

A medical home recognises that ‘ the real work’ in improving health is done by the patient and their families. There is  a focus on empowering people to better manage their own health to the extent that they are able to. A Medical Home partners with patients, carers, and family to ensure cultural preferences and values are respected. Patients receive the education and support they need for shared decision making. Patients have the opportunity to participate in the design of the care systems in a medical home.

Comprehensive and Continuous Care

“Provide or help us get the health care, information and services we need”[2]

The medical home provides whole person care. It is responsible for the range of each patient’s physical and mental healthcare needs – including prevention and wellness, acute care and the management of long term conditions.  It will either provide care itself, or make sure that people can access the most appropriate provider for all their health needs.

A medical home adopts a team based approach that includes providers with a range of skills, including care management and coordination.

“Be our partner in time in caring for us”[2]

Care in the medical home is continuous – each patient has an ongoing relationship with a particular GP and the medical home team.

The team based approach allows for continuous care – every staff member in a patient centred medical home is expected to have an independent relationship with patients and families on their team. Patients are the most important member of the team and help design workflows for the practice.

The medical home provides whole person care. It is responsible for the range of each patient’s physical and mental healthcare needs – including prevention and wellness, acute care and the management of long term conditions. It will either provide care itself, or make sure that people can access the most appropriate provider for all their health needs.

The medical home recognises the whole population for whom it cares and is proactive in recognising people who are missing out on care – especially those from disadvantaged groups. It reaches out to support patients who need help with a variety of needs – social, emotional, financial and beyond.


Coordinated Care

“Help us navigate the health care system to get the care we need in a safe and timely way”[2]

The medical home accepts accountability for a patient’s care, even when that person is not standing in front of them.

The medical home is a gateway to the rest of the health system, which it assists patients to navigate. It ensures each patient can access the full team they need to manage their health, which includes arranging and coordinating care with other providers. This may sometimes include hospital inpatient care. It tries to ensure that each patient receives the best possible care from all members of their care team.

A medical home is the curator of each person’s medical history, and maintains accurate clinical records.

The medical home works to ensure each person experiences integrated (joined-up) health care, in which there is consistency of information between all team members with clear roles, goals and communication pathways.

A medical home advocates for its patients by promoting a person centred health system.

Accessible Care

“Health care team, be there when I need you”[2]

In a medical home, patients can access care for their acute or routine medical needs when they require it. Arrangements are clear for urgent out of hours care. The medical home is also proactive in managing chronic conditions.

In a medical home, access is  more than coming in for a visit –  access is also answering questions over the phone or email when a visit is not necessary. In many Patient Centred Medical Homes, telemedicine and home visits are being used to provide timely and convenient care to patients.

Additionally, text messaging, social media and other asynchronous tools are also encouraged to keep patients up to date on important health considerations and aware of upcoming appointments.


Focus on Quality and Safety

“Take responsibility for making sure we receive the best and safest possible health care.”[2]

A medical home has a system based approach to make sure that each patient receives the highest quality care by implementing systems to improve patient safety.

It engages all staff to identify and follow patient population and disease specific needs, and it uses a technique called Continuous Quality Improvement to drive performance to the highest levels.


Do medical homes exist in Australia?


There are very many  practices and aboriginal medical services in Australia that provide high quality comprehensive care. They already function as medical homes for the communities they serve.

However, whereas all medical homes in Australia are general practices or aboriginal medical services, not all general practices or aboriginal medical services are acting as medical homes.

A medical home is a practice that commits to providing the highest levels of care following the principles detailed above to the people who have chosen it.

See also

The Person Centred Health System

Medical Home FAQs




  1. Defining the Medical Home. A patient-centered philosophy that drives primary care excellence. The Patient Centered Primary Care Collaborative
  2. Implementation of Oregon’s PCPCH Program: Exemplary Practice and Program Findings
  3. Joint Principles of the Patient-Centered Medical Home March 2007 https://www.acponline.org/system/files/documents/running_practice/delivery_and_payment_models/pcmh/demonstrations/jointprinc_05_17.pdf
  4. What is the Patient Centered Medical Home. American College of Physicians