Before I attempt to explain population health, It is a good idea to explain the Patient Centered Medical Home (PCMH) framework around it. Simply put, PCMH is a model in which primary care is organized and delivered. It is an active evolution of the primary care physician (PCP) practice. Below are the five main components to PCMH.

  1. Comprehensive Care
    • PCMH’s goal is to be a, “one stop shop” for patients and their medical and mental needs. Inside my current practice, we have physicians that practice family and OB-GYN medicine, behavioral health, nurse clinical care management (my role, managing the medical challenges), and health home care management (managing the social challenges).
  2. Patient-Centered
    • One of the most difficult things to administering health care is that for any given medical situation there is the ideal treatment, and then there is the patient-centered treatment. Patient-centered care takes into account the patient, family, financial situation, cultural considerations, and other various social determinants that represent barriers to the care they need.
  3. Coordinated Care
    • Health care systems are big, overly complicated, and confusing for patients. The coordinated care function of PCMH connects all the available resources both inside and outside the practice. It is especially critical during transitions of care (i.e. being discharged from the hospital or skilled nursing facility).
  4. Accessible Resources
    • The PCMH aims to increase patient access to the health care system. This can happen in a number of different ways from extended office hours, acute same-day appointments, shorter waiting times for urgent needs, and improved electronic communication. These provide a number of different ways to offer access based on patient preferences.
  5. Quality & Safety
    • Through the aforementioned points, PCMH helps improve the quality of the patient experience. We track just about everything and we have data to analyze the effectiveness of our efforts to keep hospital readmission rates to a minimum, determine which patients are compliant with health maintenance, and see health trends to administer preventive care prior to a health crisis.

In proof reading this short piece, I may have raised more questions that I have answered. I will do my best to refine this information down to its simplest form. Please ask questions as they come up!

Source: Defining the PCMH (AHRQ)