Person-Centred Medical Home Program

Person Centred Medical Home Program

A Person Centred Medical Home combines the traditional core values of family medicine – providing comprehensive, coordinated, integrated, quality care – that is easily accessible and based on an ongoing relationship between a person and their health care team.
SNHN provides support and education to the healthcare team to help the practice achieve the quadruple aim:

  • Enhance the patient experience of care.
  • Improve systems and efficiencies.
  • Optimise population health and wellbeing.
  • Improve the work life of health care clinicians.
PCMH in action

Key Principles

Key principles

Building Blocks

1. Engaged Leadership

How well do you know your leadership style and the effect it has on your health care team? Everyone is a leader, however in the medical home General Practitioners are central to the success of driving change and achieving outcomes.

2. Data-Driven Improvement

Using a data extraction tool alongside clinical software to understand the practice patient population is invaluable when managing the requirements of the person centred medical home. Make data part of the work life.

3. Empanelment (Patient Registration)

This involves linking each patient with a primary care provider and care team. To improve continuity and establish a strong patient-team partnership it is important that patients and the care team know each other and plan the care together.

4. Team-Based Care (Building the Team)

Creating more effective practice teams is the key to becoming a patient-centred medical home, improving patients’ health, and increasing productivity. A team-based approach can lead to markedly improved care, efficiency, and job satisfaction.

5. Patient-Team Partnership

An effective partnership recognises the expertise that patients bring to the medical encounter as well as the evidence base and medical judgment of the clinician and team. Patients are not told what to do but are engaged in shared decision making that respects their personal goals.

6. Population Management

High-performing practices stratify the needs of their patient panels and design team roles to match those needs. Three population-based functions provide major opportunities for sharing the care: panel management, health coaching, and complex care management.

7. Continuity of Care

Is associated with improved preventive and chronic care, greater patient and clinician experience, and lower cost. To achieve continuity requires empanelment linking each patient to a clinician and team.

8. Prompt Access to Care

Access is linked to patient satisfaction and is a prominent objective for many practices. Though the science of access is well-developed, practices frequently fail in their efforts to reduce patient waiting time.

9. Comprehensiveness and Care Coordination

Refers to the capacity of a practice to provide most of what patients need. Another pillar – care coordination – is the responsibility of primary care to arrange for services that primary care is unable to provide.

10. Template of the Future

Few practices have achieved this ultimate goal: a daily schedule that does not rely on the 15-minute in-person clinician visit but offers patients a variety of e-visits, telephone encounters, group appointments, and visits with other team members.


Sue Barry, PCMH Program Lead
T: (02) 9432 8221, E: sbarry@snhn.org.au

Education Opportunities and Resources

Covering a range of topics, the webinars aim to equip practice staff with enhanced knowledge for growing a thriving, high-performing general practice.

Webinar 1: Reaching Business and Financial Potential
Presented by: David Osman, Practice Manager; Healthcare Trainer; and Board Director, AAPM
Webinar air date: Wednesday 18 August at 7pm

Register using the form below to access webinar recording and resources.

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