needs children, and expanded to embrace the consensus view of primary care as first-contact, comprehensive, continuous, coordinated care for all populations (IOM, 1996; Starfield and Shi, 2004). This model is joined by key elements of Wagner’s Chronic Care Model (Wagner et al., 1996), several system redesign features (e.g., interdisciplinary collaboration and fully integrated HIT), and a new payment structure that recognizes the broad set of services comprising the patient-centered medical home (Berenson et al., 2008). The PCMH is intended to address critical deficiencies in the current primary care system: (1) making the “patient” the focus of and place for care—redesigning practice so that it is truly “centered” on patient and caregivers; (2) meeting the growing challenge of managing chronic illnesses in primary care settings; and (3) providing necessary resources and payment for care management and coordination activities required for an effective PCMH (Berenson et al., 2008; Chokshi, 2009; Rittenhouse et al., 2009).

A fully functional PCMH is founded on patient and caregiver engagement in care that meets patient preferences; information and education that promotes self-management; care coordination that monitors, reviews, and follows up on all services needed and provided across settings; secure transitions across health care settings; and effective information flow across all providers and services to assure integrated care delivery (Davis et al., 2005; Gerteis et al., 1993). This PCMH model is envisioned to result in lower costs through reductions in emergency room visits and hospital admissions (Hussey et al., 2009; Eibner et al., 2009). Patient self-management, care coordination, and transitional care—services at the core of the PCMH and shown to result in lower hospital and ER use—are directed and provided by nurses.

The Guided Care Program offers an example of a successful PCMH model, one that has improved patient outcomes and quality and reduced health care costs through nursing services (Boult et al., 2008; Boyd et al., 2007, 2008; Leff et al., 2009; Sylvia et al., 2008). The Guided Care (GC) model is a PCMH program using an interdisciplinary team approach to coordinate care for older adults with complex chronic conditions. Based in primary care physician practices, GC nurses coordinate care among health care providers; complete standardized comprehensive home assessments; and collaborate with physicians, patients, and caregivers to create and execute evidence-based care guides and actions plans. GC nurses work on a long-term basis with clients, provide transitional care, and assist patients with self-management skills and accessing necessary community-based services (Boult et al., 2008). Early findings from a cluster randomized trial of this program reveal a 24 percent reduction in inpatient days, 15 percent reduction emergency room visits, and a net Medicare savings of $75,000 per GC nurse in the programs (Leff et al., 2009).

The Intermountain Healthcare Medical Group in Utah (Dorr et al., 2008) and the Geriatric Resources for Assessment and Care for Elders (GRACE) program in Indiana (Counsell et al., 2007) are PCMH models that have targeted high risk older adults for rigorously coordinated care provided by nurses embedded in

The National Academies of Sciences, Engineering, and Medicine
500 Fifth St. N.W. | Washington, D.C. 20001

Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement