What is a Medical Home?
A person centred medical home is the general practice which is chosen by a person to be responsible for their ongoing, comprehensive, whole-person medical care.
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.
The medical home coordinates the care delivered by all members of a person’s care team, which may sometimes include hospital inpatient care. The medical home ensures that each person experiences integrated (joined-up) health care.
The Patient Centred Medical Home is a model for health care that has been demonstrated to be effective, efficient and welcomed by patients and providers.
What are the attributes of a Medical Home?
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.
A medical home will have systems to foster self management of each person’s health
Patients will be able to participate in the design of the services that a medical home offers.
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.