“It really comes down to relationships.”

This is how Amy Gibson RN, MS, and Chief Operating Officer at The Patient-Centered Primary Care Collaborative (PCPCC) describes the foundation of the Patient-Centered Medical Home (PCMH) model of care. “It’s about a strong, trusted partnership between the primary care team and an individual. Whoever is a member of that team—whoever is anchored to that primary care center, and who is working alongside patients and their family—that is really what makes for an effective PCMH model,” she adds. 

The PCPCC is helping change the game when it comes to health care, advocating an effective health system that’s founded on primary care and the PCMH.

From experts to thought leaders, the PCPCC works to educate and to advocate individuals, stakeholder groups, partners, medical professionals, and even Congress on the PCMH. Each year, the PCPCC collects and disseminates information as it relates to medical homes, including best practices and innovative strategies. We talked with Amy Gibson about how we can go about actually defining the “medical neighborhood” as we go forward.

Gibson explains how the PCPCC has adopted a broad definition. “[The medical neighborhood] is really connecting everyone who is impacting the health of an individual patient. It’s the caregivers, or the families—it is not just your traditional health care, or medical services in that way. It could be YMCAs, faith-based organizations, child care, schools, workplaces even.”

In this way, the PCPCC recognizes that an individual’s unique “medical neighborhood” is a reflection of all the facets of health for that specific person, at that specific point in his or her life. “It’s what makes sense for that individual patient, however they see fit, or what they see as a part of their team…so the ‘medical neighborhood’ for them embraces that,” adds Gibson. 

So then, what might define an effective PCMH within that patient’s unique medical neighborhood?

That’s where the relationship-driven structure comes in. These strong relationships between clinician/care teams and patient provide a framework for which people can create and better set themselves up for true behavior-based changes that result in better health outcomes.

And in terms of those desired outcomes, we know the evidence is strong that when patients have a trusting relationship with their health professional, they are then more likely to embrace overall goals related to their health. “Of course these goals have to be the patient’s goals, not just the provider’s goals,” says Gibson.

That being said, there’s a bit of misunderstanding about patients in terms of care delivered through a medical-home approach at times. 

“One of the biggest misconceptions, and its really more of an assumption, can come from healthcare providers,” says Gibson. “Some have taken the stance that patients do not, or would not, want care from any one other than their doctor.”

Research has shown, however, quite the opposite to be true: patients want team-based care, and they want to be interfacing with a variety of experts to better their care and get that community-based support.

For those centers looking to become PCMH-designated, the process is certainly an evolution, Gibson points out. Often times, that evolution starts with a focus on the idea of access for patients. And often, one of the first things centers are able to see as a result of this evolution is in fact a cost savings as it relates to that improved access. 

“We see decreased ER utilization for primary care-related purposes, decreased readmissions to practice due to better transitions, and that increased access to primary care in general. Those are just some of the early-on wins in medical homes in terms of cost savings,” explains Gibson.

While cost savings may be seen in the short-term, it’s also valid that quality indicators—while they certainly change over time—typically take longer to see evidence of, but they do improve. 

Notably, these improvements in care and in quality indicators are seen with chronically ill patients, the most costly of patients. “Medical homes show improvements with diabetes and hypertension, as two examples. Those are big ones. The [medical homes] often carve out a particular portion of their population, and then they are able to really deliver better care to that segmented group. Even with ‘first out of the gate’ efforts, they see the result of a better way to care,” Gibson says. And this can happen in a variety of ways, with a variety of payer mixes.

One thing is becoming clear: team-based care is the way to improving health care.

It’s about improving patient quality and satisfaction, reducing costs, and improving the health of populations.


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