Patient-Centered Medical Home (PCMH) and Patient-Centered Specialty Practice (PCSP)

The Patient-Centered Medical Home (PCMH) and the Patient-Centered Specialty Practice (PCSP) offer centralized, coordinated care for patients, whether in a long-term primary care setting or in a specialty requiring communication between primary and specialty care. Some programs and payers, including Medicare’s Quality Payment Program, offer incentives to practices that are recognized as a PCMH or PCSP.  

• Joint Principles of the PCMH: In March 2007, the primary care professional societies endorsed a set of joint principles. Since then, these principles have now been endorsed and reaffirmed by many more physician organizations.   
• Joint Guidelines for Patient-Centered Medical Home Recognition and Accreditation Programs (March 2011): These Guidelines, developed jointly by ACP, AAFP, AAP, and AOA, are intended to ensure some standardization among PCMH Recognition and Accreditation Programs while encouraging a focus on the key elements of the PCMH.  
• Joint Principles for the Medical Education of Physicians as Preparation for Practice in the PCMH (December 2010): These principles, developed jointly by ACP, AAFP, AAP, and AOA, guide medical school curricula in ensuring that all physicians, regardless of their specialty choice, will have the expertise to practice in a health care delivery system based on the patient-centered medical home.  
• High Value Care Coordination (HVCC) Toolkit: A collaboration between the American College of Physicians (ACP), Council of Subspecialty Societies (CSS) and patient advocacy groups, the HVCC Toolkit provides resources to facilitate more effective and patient-centered communication between primary care and subspecialist doctors. Included are “pertinent data sets” needed for transferring patients to specialty care, model referral request and response checklists, and care coordination agreements. 

ACP PCMH/PCSP Policy  

• Envisioning a Better US Health Care System for All: Health Care Delivery and Payment System Reforms (2020) 
• Reforming Physician Payments to Achieve Greater Equity and Value in Health Care (2022) 
• Beyond the Referral: Principles of Effective, Ongoing Primary and Specialty Care Collaboration (2022) 
  • Beyond the Referral Playbook 
• The Patient-Centered Medical Home Neighbor: The Interface of the Patient-Centered Medical Home with Specialty/Subspecialty Practices (2010) 

PCMH/PCSP Resources 

• Primary Care Collaborative: The Primary Care Collaborative (PCC) is a multi-stakeholder membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home.  
  • Shared Principles of Primary Care: These principles, which build on the 2007 PCMH Joint Principles, include the 7 key attributes of advanced primary care. They have been endorsed by 100s of organizations across the healthcare spectrum. 
  • Investing in Primary Care: A State-Level Analysis (2019): examines states’ primary care spending patterns, including spending across payer types, and considers the implications of these results for select patient outcomes.  
  • Primary Care and COVID-19: It’s Complicated (2021): Each year, the PCC conducts an annual review of publications that summarize program outcomes for PCMH initiatives. 
• Implementing High-Quality Primary Care: This landmark 2021 report from the National Academy of Sciences, Engineering, and Medicine (NASEM) examines the current state of primary care in the US and offers an implementation plan for high-quality primary care. 
• Agency for Healthcare Research and Quality (AHRQ) PCMH: Provides objective information to policymakers and researchers on the medical home, including a searchable database of publications and other relevant resources.  
• National Medical Home Recognition and Accreditation Programs: the following national organizations have developed medical home recognition and accreditation programs that have been recognized by payers in different geographic areas.  
  • NCQA Patient Centered Medical Home (PCMH) Recognition Program 
  • URAC Patient Centered Medical Home Recognition Program  
  • Joint Commission Primary Care Medical Home Program  
  • Accreditation Association for Ambulatory Health Care Medical Home Program  
• The National Academy for State Health Policy (NASHP) tracks health policy at the state level.  
• The Commonwealth Fund 
  • Review of Medical Homes Shows Reduction in Spending for High-Risk Patients, But Design and Implementation Matter (2017)