Patient Centered Medical Home

Primary Care Residency Program

The ACP 2006 monograph recommends that: "medical education and training will need to change to better prepare young physicians for practice under the advanced medical home model".

PCMH objective Program Specifics to Achieve Objectives
Personal physician ‐ each patient has an ongoing relationship with a personal physician trained to provide first contact, continuous, and comprehensive care. Each resident is teamed with one preceptor familiar with the patient panel. This ensures continuity for the patient and attending while providing a good framework for the trainee.
Physician‐directed medical practice - the personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients. The Attending leads a team of residents to ensure continuity, urgent care and timely hospital following up.
Whole person orientation- the personal physician is responsible for providing for all of the patient's healthcare 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 all end-of-life care. Residents are responsible for setting up consultative services, providing home care options and visiting their patients in the hospital. Preventive services are an integral part of the outpatient curriculum.

Care is coordinated and/or integrated across all elements of the complex healthcare system (e.g., subspecialty care, hospitals, home health agencies, nursing homes) and the patient’s community 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 are 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.
  • Physicians in the practice accept accountability for continuous quality improvement though voluntary engagement in performance measurement and improvement.
  • Patients actively participate in decision-making and feedback is sought to ensure patients expectations are being met.
  • Information technology is utilized appropriately to support optimal patient care, performance measurement, patient education, and enhanced communication.
  • 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.

The program is set up to involve trainees directly in all aspects of patient care allowing them to develop an appreciation for the entire health care system. Cultural competency and literacy and important topics addressed in the program.

Trainees are responsible for collecting data and assessing outcomes of their patient panel. This is a core medical home component. A continuous environment of quality improvement activities are incorporated in the training program. Patient surveys are obtained.

Attendings and residents share test results through the EMR system (currently we use Healthlink). This gives the trainee an opportunity to be involved in patient care between clinic visits. Trainees learn what the specific qualifications are for NCQA recognition

Enhanced access to care is available through systems such as open scheduling, and expanded hours, and email access The patient care schedules provide for timely visits to ensure that patients are seen by their PCP or urgently by a member of the team if the PCP is not available.
Payment appropriately recognizes the added value provided to patients who have a PCMH. Residents are not directly involved in this process.

Primary Care residents provide continuity care at two medical home locations, the Seifert and Ford Family Community Health Center and the Greater Danbury Community Health Center. Residents also rotate through private practice medical home sites. All locations provide the residents with a diverse mix of ages, socioeconomic and ethnic backgrounds, chronic and acute illnesses; this allows the residents to gain experience in diagnosing, evaluating and managing a wide variety of illness and health promotion issues in the longitudinal care setting.

For More Information

Please contact us if you have questions about the Internal Medicine Residency Program at Danbury Hospital, or would like more information.