The MA PCMHI Council advised that a practice should possess the following core competencies in order to be recognized as a PCMH:

1. Patient/family-centeredness: This means that longitudinal care is delivered with transparency, individualization, recognition, respect, linguistic and cultural competence, and dignity. Such care also provides patients/families/caregivers with choice in all matters and possesses an ongoing focus on consumer service, with bi-directional feedback.

2. Multi-disciplinary team-based approach to care: This is a less physician-centric hierarchical model for care delivery than is found in traditional primary care practice and is one that requires effective team communication, collaboration and role definition.

3. Planned visits and follow-up care: In contrast to episodic, reactive care, this manner of primary care delivery tracks patients on an ongoing basis so that the practice is informed and ready to address the patient's needs holistically whenever the patient makes contact, and follows up with patients after encounters, as necessary.

4. Population-based tracking and analysis with patient-specific reminders: To support planned visits and follow-up care, a practice needs information tracking capacity in the form of a freestanding or Electronic Health Record (EHR) based patient registry with reporting functionality.

5. Care coordination across settings, including referral and transition management: Practices assume responsibility for tracking and assisting patients as they move across care settings, and for coordinating services with other service providers including behavioral health and social service providers.

6. Integrated care management focused on high-risk patients: For the most clinically at-risk patients in a practice, a care manager is either a) based in the practice or b) residing outside of the practice but otherwise tightly integrated with the practice team.

7. Patient and family education: The practice team educates patients and family members both on primary preventive care, and on self-management of chronic illness (i.e., secondary preventive care).

8. Self-management support by all members of the practice team: Extending beyond education, self-management support assists the patient and/or family/caregiver with the challenges of ongoing self-management, directly and/or through referral.

9. Involvement of the patient in goal setting, action planning, problem solving and follow-up: Patient-centered primary care requires care planning and related activities focused on a patient's specific circumstances, wishes and needs.

10. Evidence-based care delivery, including stepped care protocols: Care should be evidence-based wherever evidence exists, and follow stepped protocols for treatment of illness.

11. Integration of quality improvement strategies and techniques: Practices should utilize the improvement model emphasized by the Institute for Healthcare Improvement to measure performance, identify opportunities for improvement, test interventions and reassess performance.

12. Enhanced access: Another hallmark of patient-centered primary care is the availability of easy and flexible access to the primary care team, including alternatives to face-to-face visits, such as e-mail and telephone.


This information is provided by the Executive Office of Health and Human Services.