The Joint Principles established by the AAFP, AAP, AOA and ACP, which form the basis of the medical home certification process, define a PCMH as a practice that meets the following core criteria:

A)    Personal Physician: Each patient has an ongoing relationship with a doctor that provides continuous, comprehensive primary care.

B)   Physician-Directed Practice: A patient’s personal physician leads a team of other physicians and non-physician health professionals who collectively take responsibility for ongoing care.

C)   Whole Person Orientation: Part of the primary care doctor’s responsibility is to prevent as well as treat chronic diseases, and to address all aspects of a person’s life across all life stages.

D)   Coordinated, Integrated Care: The PCMH becomes the locus of coordination between specialists, hospitals, home care agencies, nursing homes, and community based services. Good coordination hinges on well-designed information technology systems (EMRs, PHRs, registries).

E)   Quality & Safety Are Paramount: PCMH doctors are patient advocates, using evidence-based guidance and patient education tools to ensure that patients make informed and intelligent choices. PCMH physicians must be committed to accountability and ongoing quality improvement.

F)    Enhanced Access: Open scheduling, expanded hours, email access, and digital interconnectivity are cornerstones of PCMH.

G)   Appropriate Reimbursement: Physician payment should reward the added value that a PCMH practice brings to health care, and should recognize the time, energy and effort of physicians and non-physician staff, while also supporting implementation of health IT. Physicians should share in the savings from reduced hospitalizations and lower utilization of acute care, with additional payment for reaching quality improvement goals. Payment should be a mix of fee-for-service for face-to-face visits, and monthly per-patient fees to cover care management that occurs outside the office (eg. Email, teleconsults, etc).