Key Principles of Patient Centred Medical Homes

1. Comprehensive care

The Patient Centred Medical Home (PCMH) is responsible for meeting the large majority of each patient’s physical and mental healthcare needs. This includes prevention and wellness, and acute and chronic care.

Comprehensive care like this requires a team of healthcare providers. The team may include general practitioners (GPs), practice nurses, pharmacists, dieticians, social workers, educators and care coordinators. Some medical home practices assemble large and diverse teams of care providers to meet their patients' needs. However, many others, including smaller practices, build virtual teams to link themselves and their patients to providers and services in their communities.1

The following comprehensive care strategies have been identified.

  • The care team focuses on the whole person and population health.
  • Primary care can co-locate with behavioural or oral health, vision, obstetrics and gynaecology, and pharmacy.
  • The care team gives special attention to people with chronic disease and complex healthcare needs.2

2. Patient-centred

The patient centred medical home provides healthcare that is relationship-based and oriented to the whole person. Partnering with patients and their families requires understanding and respect for each patient’s unique needs, culture, values and preferences. The medical home practice actively supports patients as they learn to manage and organise their own care at a level of their choosing. Medical homes recognise patients and families as core members of the care team, and ensure they are fully informed partners in establishing care plans.1

The following patient-centred strategies have been identified.

  • Dedicated staff help patients navigate the system and create care plans.
  • The focus is on strong, trusting relationships with physicians and the care team, with open communication about decisions and health status.
  • Care is compassionate and culturally sensitive.2

3. Coordinated care

The patient centred medical home coordinates care across all elements of the broader healthcare system (the healthcare neighbourhood). This encompasses specialty care, hospitals, aged care providers, home healthcare, and community services and supports. This coordination is particularly critical during transitions between sites of care, as when patients are discharged from hospital. Medical home practices also excel at building clear and open communication among patients and families, the medical home, and members of the broader care team within the healthcare neighbourhood.1

The following coordinated care strategies have been identified.

  • Care is documented and communicated effectively across providers and institutions, including patients, primary care, specialists, hospitals, home health and so on.
  • Communication and connectedness is enhanced by health information technology.2

4. Continuity of care

The patient centred medical home facilitates continuity of care through a team-based approach to healthcare, with the GP as the team leader. The patient and their care team cooperate in ongoing healthcare management, toward the shared goal of high-quality healthcare.

Continuity of care helps general practitioners gain their patients’ confidence and become more effective patient advocates. Continuity of care is rooted in a long-term patient-doctor partnership. The GP knows the patient’s history from experience, and can integrate new information and decisions from a whole-person perspective efficiently, without extensive investigation or record review.3

The following continuity of care strategies have been identified.

  • Implementing PCMH principles has been shown to increase continuity of care.4
  • Improved accessibility makes it easier for patients to connect with their preferred care provider.

5. Accessible services

The patient centred medical home delivers accessible services, with shorter waiting times for urgent needs, enhanced in-person hours, around-the-clock telephone or electronic access to a member of the care team, and alternative methods of communication such as email and telephone care. The medical home practice is responsive to patients’ preferences about access.1

The following strategies for accessible services have been identified.

  • More efficient appointment systems offer same-day or 24-hour, 7-day access to the care team.
  • E-communication and telemedicine provide alternatives to face-to-face visits and allow for after-hours care.2

6. Quality and safety

The patient centred medical home demonstrates commitment to quality and quality improvement. It achieves this through ongoing engagement in activities such as: evidence-based medicine and clinical decision-support tools to guide shared decision-making with patients and families; engaging in performance measurement and improvement; measuring and responding to patient experiences and patient satisfaction; and practicing population health management. Publicly sharing robust quality and safety data and improvement activities is also an important marker of a system-level commitment to quality.1

The following quality and safety strategies have been identified.

  • Electronic health records, clinical decision support and medication management improve treatment and diagnosis.
  • Clinicians or staff monitor quality improvement goals, and use data to track populations and their quality and cost outcomes.2

Numerous academic papers discuss patient centred medical home principles. These papers vary somewhat in their descriptions of the model's key principles. For the most part, however, they differ only on how these principles are grouped and labelled. In Australia, some discussion has taken place about whether to include training of healthcare providers as an essential feature of PCMH activity. The current consensus, however, regards training as a non-essential feature, since it is not directly patient-centred.


  1. Agency for Healthcare Research and Quality. Defining the PCMH [Internet].Rockville: Agency for Healthcare Research and Quality; 2017 [cited March 2017]. Available from:
  2. Patient Centred Primary Care Collaborative. Why the medical home works: a framework [Internet]. 2015. Available from: ,
  3. American Academy of Family Physicians. Continuity of care, definition of [Internet] American Academy of Family Physicians [cited March 2022]. Available from:
  4. Perry RJ, McCall N, Wensky SG et al. Care continuity in a patient-centered medical home setting. Research Triangle Park: RTI Press; 2008. Available from: