Uncompahgre Medical Center (UMC) is a NCQA-recognized Patient Centered Medical Home organization. The patient-centered medical home (PCMH) is a model of care that aims to transform the delivery of comprehensive primary care to children, adolescents, and adults. Patient centered means services are provided at a time and in a way that is best for the patient and family, as determined by the patient, whenever possible. UMC has created care teams to improve continuity and quality of care. The patient’s team provides continuous and comprehensive care to patients throughout their lives including preventative, chronic, and acute care. Members of the care team get to know each patient over time. This results in personalized, appropriate care from a team that really knows their patients. A major component to the PCMH is increased access to care. Patients can contact their team directly during business hours via phone or after hours via secure messaging. Patients commit to providing their PCMH with a complete medical history and information about care obtained outside the practice as well as actively participating in their care in the PCMH. In return the PCMH coordinates patient care across multiple settings. As a result the team becomes a resource for evidence-based care and self-management support for the patient with the ultimate goal of making patients and their families healthier and while allowing them to remain in their community.

The medical home must encompass five functions and attributes:

1. Comprehensive Care
The primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. Providing comprehensive care requires a team of care providers.

2. Patient-Centered
The primary care medical home provides primary health care that is relationship-based with an orientation toward the whole person. Partnering with patients and their families requires understanding and respecting each patient’s unique needs, culture, values, and preferences. The medical home practice actively supports patients in learning to manage and organize their own care at the level the patient chooses. Recognizing that patients and families are core members of the care team, medical home practices ensure that they are fully informed partners in establishing care plans.

3. Coordinated Care
The primary care medical home coordinates care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports. Such coordination is particularly critical during transitions between sites of care, such as when patients are being discharged from the 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.

4. Accessible Services
The primary care 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 regarding access.

5. Quality and Safety
The primary care medical home demonstrates a commitment to quality and quality improvement by ongoing engagement in activities such as using 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