Patient Centered Medical Home

• Responsible for meeting the patient’s physical and mental health care needs
• This team may include: Physicians, APRNs, PAs, RNs, Behavioral Health Therapists, Pharmacists, Nutritionists, and Care Coordinators
• Provides care that addresses various phases of patient’s lifespan, including end of life
• Provides disease and chronic care management services to its patients

• Provides care that is relationship-based geared towards the whole person
• Practices supports patients in learning to manage and organize their own care at a level the patient chooses

Coordinates care across all elements of health care system including: specialty care, hospitals, home health care, and community services and supports

Delivers accessible services with short waiting times for urgent needs, enhanced in-person hours, 24/7 telephone or electronic access to a member of the care team, and alternative methods of communications such as email, telephone care, and patient portal

• Demonstrates a commitment to quality and quality improvement by using evidence based medicine and clinical decision support tools to guide shared decision making with patients and families 
• Evaluates how effectively the primary care clinician and team work in partnership with the patient to support the continuity of care and the provision of comprehensive and coordinated care, treatment, or services
• Organization wide patient safety program in which all departments participate