Care management and care coordination within a patient-centered medical home

Abstract

OBJECTIVE The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH). BACKGROUND The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care. METHODS A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted. RESULTS Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems. CONCLUSIONS Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.