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Patient Centered Medical Home

May 26, 2015

Approximately a year ago, our practice embarked on a journey that eventually lead us to receive recognition as a Patient-Centered Medical Home (PCMH). We received our notice this past week and are excited about the opportunities this experience might bring to our practice.

The National Committee for Quality Assurance (NCQA) describes the PCMH as “a health care setting that facilitates partnerships between individual patients and their personal physicians, and when appropriate, the patient’s family. 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.” Of course, the statement is not completely correct because partnerships also exist with other providers including diabetes educators.

AADE is currently working on a demonstration project with five universities “to explore the feasibility of incorporating a multilevel diabetes education team into the PCMH,” according to the September/October 2011 issue of The Diabetes Educator. Being a diabetes educator made the certification process more manageable and attainable because many of the PCMH elements incorporate what diabetes educators already do. Recently, American Medical News posted an article about innovative primary care practices (including PCMHs) who might receive incentive payments for the way they provide care. 

When I read about this type of innovative program, I envision the many opportunities for diabetes educators. Perhaps this could be tied to direct reimbursement for diabetes educators? While I’m optimistic about our PCMH recognition, I can't help but wonder how our patients and practice might benefit.

Is anyone else working in a PCMH? If so, how has DSME delivery changed?


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  1. Nov 21, 2011

    I would like to know if anyone that has a medical-home program/certification has developed the specific role & responsibilities of the health coach (RN - care manager), the diabetes educator and the dietitian? I am trying to help clarify the various roles and how we can synergistically work to achieve better care for our patients with diabetes. I would appreciate any information or clarification that you may have.
  2. Nov 04, 2011

    PCMH appears to be a model in a primary care practice environment. How would it work in specialty care, e.g. Endocrinology?

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