A patient-centered medical home, or PCMH, is a model for organizing primary care. The word “home” describes the relationship and coordination around the patient; it does not mean a residential facility or a requirement that care occur in the patient's house.
AHRQ describes five central features: comprehensive care, partnership with patients, coordination, access, and attention to quality and safety. A practice may use an on-site team or connect with professionals and services elsewhere in the community.
Translate the model into an ordinary patient journey
Consider what happens before, during and after an appointment. Who helps prepare the visit? How does the patient raise a concern between appointments? Who sees recommendations from an outside specialist?
These questions make the model concrete. A practice may describe itself as coordinated, but a nurse still needs a defined route for unresolved work.
In a fictional example, a patient returns after a specialist consultation with a plan the primary-care team has not received. The nursing workflow should identify how to obtain the information, who reviews it and how the patient learns the agreed next step. Simply adding another appointment does not resolve the missing connection.
Know the nursing contribution
Ask how the practice divides responsibility for education, triage, follow-up, referrals and care management. Clarify which functions belong to the particular nursing position and how clinical consultation is available.
The model's emphasis on partnership also calls for attention to the patient's preferred level of involvement. AHRQ describes patients and families as informed partners in care planning, with respect for their needs and preferences.
Use the patient's own priorities when preparing a plan or follow-up conversation. Check whether the instructions are workable at home, and bring unresolved barriers back to the team.
Distinguish the model from recognition
NCQA operates a PCMH Recognition program with criteria across six concept areas. These include team organization, access and continuity, care management, coordination and quality improvement. A practice must demonstrate performance against the program's criteria to earn that recognition.
The conceptual model and a named organization's recognition are related, but different claims. When a practice advertises recognition, verify the program and the site involved. Do not infer current recognition merely from the use of “medical home” in a job advertisement.
Recognition information can support a workplace discussion, but it does not answer every question about a specific assignment.
Ask how the model is sustained
Explore the resources behind the promise: time for follow-up, coverage during absences, useful records, access to other disciplines and a process for improving recurring problems.
Ask how the practice gathers patient feedback and how staff can show that a transition or referral failed. A team needs a way to examine its actual work, including the gaps patients report.
For a practical way to check whether a referral reached its destination, see closed-loop referrals.
Related pages cover integrated behavioral health, shared decision-making and care plans across organizations.
Sources
- Defining the PCMH (accessed 2026-09-17) — AHRQ, reviewed August 2022.
- NCQA PCMH Recognition: Concepts (accessed 2026-09-17) — NCQA.