JOINT PRINCIPLES: INTEGRATING BEHAVIORAL HEALTH CARE INTO THE PATIENT-CENTERED MEDICAL HOME
The Patient-Centered Medical Home (PCMH) is an innovative, improved, and evolving approach to providing primary care that has gained broad acceptance in the United States. The Joint Principles of the PCMH, formulated and endorsed in February 2007, are sound and describe the ideal toward which we aspire. However, there is an element running implicitly through these joint principles that is difficult to achieve yet indispensable to the success of the entire PCMH concept. The incorporation of behavioral health care has not always been included as practices transform to accommodate to the PCMH ideals. This is an alarming development because the PCMH will be incomplete and ineffective without the full incorporation of this element, and retrofitting will be much more difficult than prospectively integrating into the original design of the PCMH.
Therefore we offer a complementary set of joint principles that recognizes the centrality of behavioral health care as part of the PCMH. This document follows the order and language of the original joint principles while emphasizing what needs to be addressed to insure incorporation of the essential behavioral elements. It is intended to supplement and not replace the original Joint Principles document, which still stands.
This document has been reviewed and endorsed by a number of Family Medicine and Primary Care Organizations, including the American Academy of Family Physicians (AAFP), the American Academy of Family Physicians Foundation (AAFP-F), the American Board of Family Medicine (ABFM), the Association of Departments of Family Medicine (ADFM), the Association of Family Medicine Residency Directors (AFMRD), the North American Primary Care Research Group (NAPCRG), the Society of Teachers of Family Medicine (STFM), the American Academy of Pediatrics (AAP), the American Osteopathic Association (AOA), the Collaborative Family Healthcare Association (CFHA), and the American Psychological Association (APA).
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Preceding the Joint Principles that integrated behavior healthcare in the PCMH, the original Joint Principles of the Patient-Centered Medical Home was published on Patient Centered Primary Care Collaborative (http://www.pcpcc.net) and included the five principles that still guide the PCMH model:
Each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
Physician directed medical practice
A personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
Whole person orientation
A personal physician is responsible for providing for all the patient’s health care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life; acute care, chronic care, preventive services, and end of life care.
Care is coordinated or integrated
Care is coordinated and/or integrated across all elements of the complex health care system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community (e.g., family, public and private community-based services). Care is facilitated by registries, information technology, health information exchange, and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
Quality and safety
These are the hallmarks of the medical home:
- Practices advocate for their patients to support the attainment of optimal, patient-centered
- outcomes that are defined by a care planning process driven by a compassionate, robust
- partnership between physicians, patients, and the patient’s family.
- Evidence-based medicine and clinical decision-support tools guide decision making.
- Practices go through a voluntary recognition process by an appropriate non-governmental entity to demonstrate that they have the capabilities to provide patient centered services
- consistent with the medical home model.
- Patients and families participate in quality improvement activities at the practice level.
Care is available through systems such as open scheduling, expanded hours and new options for communication between patients, their personal physician, and practice staff.
Appropriately recognizes the added value provided to patients who have a patient-centered medical home. The payment structure should be based on the following framework:
- It should reflect the value of physician and non-physician staff patient-centered care management work that falls outside of the face-to-face visit.
- It should pay for services associated with coordination of care both within a given practice and between consultants, ancillary providers, and community resources.
- It should support adoption and use of health information technology for quality improvement.
- It should support provision of enhanced communication access such as secure e-mail and telephone consultation.
- It should recognize the value of physician work associated with remote monitoring of clinical
- data using technology.
- It should allow for separate fee-for-service payments for face-to-face visits. (Payments for care management services that fall outside of the face-to-face visit, as described above, should not result in a reduction in the payments for face-to-face visits).
- It should recognize case mix differences in the patient population being treated within the practice.
- It should allow physicians to share in savings from reduced hospitalizations associated with physician-guided care management in the office setting.
- It should allow for additional payments for achieving measurable and continuous quality improvements.