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1 American Academy of Family Physicians (AAFP)

2 American Academy of Pediatrics (AAP)
3 American College of Physicians (ACP)
4 American Osteopathic Association (AOA)
5
6 Joint Principles for the Medical Education of Physicians as
7 Preparation for Practice in the Patient-Centered Medical Home
8 December 2010
9
10 INTRODUCTION
11
12 The Patient-Centered Medical Home (PCMH) is an approach to providing
13 comprehensive, continuous healthcare that is based on the foundation of a
14 healing personal relationship between a patient, their physician, and members of
15 a proactive, collaborative care team. Care provided through a PCMH is facilitated
16 through partnerships between these individuals and the patients’ families. Since
17 the original adoption of the Joint Principles of the Patient Centered Medical
18 Home in February 2007, it has been recognized that a remaining need exists for
19 a similar set of principles to guide the education of medical students, in order to
20 provide a foundation in primary care medicine and PCMH relevant for all
21 students, irrespective of their eventual specialty choice.
22
23 In June 2010, representatives from the AAFP, AAP, ACP and AOA (the original
24 organizations that ratified the Joint Principles of the PCMH) re-engaged to create
25 the following principles to guide the education of physicians who graduate from
26 medical schools within the United States. While similar principles can, and
27 should, be applied to other health professions students, it was the specific charge
28 of this committee to create training principles for physician education.
29
30 A matrix was created to support the cross-walk among the original Joint
31 Principles of the PCMH, the attributes and competencies needed to address
32 them, and the corresponding educational sub-principles to support each one. In
33 addition, each educational sub-principle was linked with the pertinent
34 ACGME/ABMS core competencies of medical education. [Appendix A]
35
36 PRINCIPLES OF THE PATIENT CENTERED MEDICAL HOME
37
38 Personal physician - Each patient has an ongoing relationship with a personal
39 physician trained to provide first contact, continuous and comprehensive care.
40
41 Attributes/Competencies Needed
42 Medical students should demonstrate knowledge about the definition of
43 patient-centeredness and must be able to demonstrate the ability to
44 provide patient centered care in their clinical encounters.
45
46 Corresponding Educational Sub-Principles
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47 Medical students are expected to:

48 1. experience continuity in relationships with patient(s) in a
49 longitudinal fashion within practices that deliver first-contact,
50 comprehensive, integrated, coordinated, high-quality and affordable
51 care.
52 2. communicate effectively and demonstrate caring and respectful
53 behaviors when interacting with patients and their families and
54 fellow professionals.
55
56 Physician directed medical practice - The personal physician leads a team of
57 individuals at the practice level who collectively take responsibility for the ongoing
58 care of patients.
59
60 Attributes/Competencies Needed
61 Medical students should be able to demonstrate collaborative care via
62 leadership skills that result in effective information exchange and teaming
63 with patients, their patients’ families, and professional associates.
64
65 Corresponding Educational Sub-Principles
66 Medical students are expected to:
67 1. work effectively with others as a member or leader of a health care
68 team or other professional group via interdisciplinary team
69 experiences (i.e. those involving nurses, social worker, case
70 managers, mental health professionals, diabetes educators,
71 community partners, pharmacists, etc).
72 2. articulate the roles, functions and working relationships of all
73 members of the team.
74 3. apply knowledge of leadership development, quality improvement,
75 change management and conflict management.
76
77 Whole-person orientation - The personal physician is responsible for providing for
78 all the patient’s health care needs or taking responsibility for appropriately
79 arranging care with other qualified professionals. This includes for all stages of
80 life: acute care; chronic care; preventive services; and end-of-life care.
81
82 Attributes/Competencies Needed
83 Medical students should be able to provide patient care that is
84 compassionate, coordinated, appropriate, and effective for the treatment
85 of health problems and the promotion of health.
86
87 Corresponding Educational Sub-Principles
88 Medical students are expected to:
89 1. demonstrate knowledge and an appreciation of life cycle concepts.
90 2. practice motivational interviewing and utilization of other tools to
91 promote patient and family engagement and health behavior
92 change.
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93 3. promote patient and family self-efficacy and shared decision-

94 making.
95 4. experience partnerships with health coaches and care coordinators
96 who care for patients with complex conditions.
97 5. demonstrate sensitivity and responsiveness to patients’ culture,
98 age, gender and disabilities via opportunities to elicit from patients
99 and/or their families their cultural, spiritual, and ethical values and
100 practices.
101 6. understand the importance of health literacy and its impact on
102 patient care and outcomes; utilize effective listening and other skills
103 in the assessment of health literacy.
104 7. describe and discuss strategies needed to address patient
105 transition(s) of care.
106
107 Care is coordinated and/or integrated across all elements of the complex health
108 system (e.g. subspecialty care, hospitals, home health agencies, nursing homes)
109 and the patient’s community (e.g. family, public and private community based
110 services). Care is facilitated by registries, information technology, health
111 information exchange and other means to assure that patients get the indicated
112 care when and where they need and want it, in a culturally and linguistically
113 appropriate manner.
114
115 Attributes/Competencies Needed
116 Medical students should be able to demonstrate an awareness of and
117 responsiveness to the larger context and system of health care and the
118 ability to effectively call on system resources to provide care that is of
119 optimal value.
120
121 Corresponding Educational Sub-Principles
122 Medical students are expected to:
123 1. know how the economics of health care systems across a
124 community, including all settings of care, affect patient care and
125 outcomes.
126 2. apply knowledge of the relationship between payment models and
127 health care delivery models.
128 3. experience the use of electronic health records, e-visits, e-
129 prescribing and electronic billing.
130 4. learn the basics of medical informatics and the technologies that
131 support care coordination, population health management, quality
132 management, care management and decision support.
133 5. understand basic principles of population health, including how
134 patient registries can be used to manage population health
135 6. use information technology to manage information, access on-line
136 medical information; and support their own education.
137 7. know and apply the principles of patient safety.
138 8. assess and recommend solutions to address patient risk during
139 transitions of care including use of tools such as care plans.
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140 9. demonstrate knowledge of community resources and the

141 importance of working with non-physician partners
142 10. understand how to collaborate with specialists from various
143 disciplines to provide patient-focused co-management of care over
144 time.
145
146 Quality and safety are hallmarks of the medical home:
147 - Advocacy for attainment of optimal, patient centered outcomes defined by
148 collaborative care planning process
149 - Evidence based medicine and clinical decision support tools guide decision
150 making
151 - Physicians accept accountability for quality improvement (QI) through
152 voluntary engagement in performance measurement and improvement
153 - Patients actively participate in decision making and patient feedback is sought
154 to assure expectations are being met
155 - HIT is used to support optimal patient care performance measurement,
156 patient education and enhanced communication
157 - Practices go through a voluntary recognition process to demonstrate that they
158 have PCMH capabilities
159 - Patients and families participate in quality improvement activities at the
160 practice level
161
162 Attributes/Competencies Needed
163 Medical students should be able to use of point-of-care evidence-based
164 clinical decision support and know principles of performance improvement,
165 measurement and how to use information to make decisions within
166 practice via interpretation of quality reports, patient and family
167 engagement, self-assessment of one’s own performance, knowledge of
168 the principles of community health assessment and awareness of the
169 need for patient and family advocacy skills.
170
171 Corresponding Educational Sub-Principles
172 Medical students are expected to:
173 1. understand evidence-based medicine as the standard of care.
174 2. participate in teams within practices as they develop a culture of
175 learning to improve the care process and patient experience.
176 3. learn how health care is operationalized outside of the hospital
177 setting.
178 4. participate in multi-disciplinary patient safety training experiences.
179 5. engage in opportunities to review quality data and recommend
180 evidence-based systems changes to respond to performance
181 measurement.
182
183 Enhanced Access to care is available through systems such as open-access
184 scheduling, extended hours, and new options for communications between
185 patients, their personal physician and practice staff.
186
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187 Attributes/Competencies Needed

188 Medical students should be able to demonstrate knowledge about the
189 rationale and principles of enhanced access and practice the use of non-
190 traditional encounter types including telephone medicine, E-visit care,
191 group visits, visits with non-physician providers, and care outside of the
192 location of the physical practice.
193
194 Corresponding Educational Sub-Principles
195 Medical students are expected to:
196 1. experience a variety of different encounter types such as face-to-
197 face, telephone and electronic messaging, home-based care and
198 group visits.
199 2. use information technology to support patient care decisions and
200 patient education.
201 3. apply knowledge of care partnership support and demonstrate
202 understanding of the role of that support in addressing patient
203 access and communication related to roles/responsibilities,
204 appointments, emergency/urgent situations, etc.
205
206 Payment appropriately recognizes the added value provided to patients who
207 have a PCMH.
208 - Recognizes and values work that is done outside of face-to-face visit
209 - Pays for care coordination, ancillary providers and community resources
210 - Supports adoption of HIT for quality improvement
211 - Supports provision of e-communication
212 - Recognizes values of physician work associated with remote monitoring of
213 clinical data using technology
214 - Maintains fee-for-service (FFS)
215 - Recognizes case mix differences
216 - Allows shared savings from reduced hospitalizations
217 - Allows for quality bonus or incentive payments for measurable improvement
218
219 Attributes/Competencies Needed
220 Medical students should demonstrate knowledge of the elements of
221 population-based care, non-visit work, and have an appreciation of the
222 value of these aspects of care through an understanding of enhanced
223 payment opportunities and both an understanding and capacity to apply
224 the principles of advocacy and effective negotiation.
225
226 Corresponding Educational Sub-Principles
227 Medical students are expected to:
228 1. know various physician payment methodologies (including those
229 encompassing of past, current and future policies).
230 2. assist patients in dealing with system complexities via advocacy
231 and negotiation
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232 3. be informed of the public and private policy development processes

233 that establish and/or influence coverage and payment
234 determinations.
235 4. understand the importance of effectively advancing those policies
236 that are in the best interests of their patients and the nation’s health
237 care system.
238 5. be familiar with current data on the overall cost of health care
239 including an understanding of the proportion of health care dollars
240 spent on various segments of the health care system, those costs
241 incurred by patients, as well as the overall costs of health care for
242 employers and the government.
243
244 RESOURCES
245
246 Adding these components to undergraduate education in a cohesive manner will
247 also require additional resources. Some of the sub-principles can be
248 implemented by adding students into already existing patient-care and practice-
249 based activities. However, in other cases, it will be necessary to dedicate faculty
250 and staff to create and oversee new experiences for the students. This may
251 require including disciplines that have not traditionally taught medical students,
252 including faculty with expertise in economics, health policy, or business
253 administration. Additionally, it may be necessary to find ways to better assist and
254 compensate community-based ambulatory practices for taking on students.
255 Finally, resources may be needed for infrastructure development to provide
256 students with the necessary tools, including access to electronic health records,
257 registries, and quality improvement tools, to experience some of the systems-
258 based aspects of the PCMH.
259
260 UNMET NEEDS
261
262 Professional development to prepare faculty for health reform changes is a
263 prerequisite to training medical students in both primary and specialty care. It is
264 recognized that resident physicians will also be integral components of medical
265 student education in PCMH concepts. Faculty development is a current unmet
266 need of this generation of faculty members with respect to how to teach medical
267 students and residents about the PCMH.
268
269 The current educational system lacks the necessary tools for the evaluation and
270 the assessment of learners with regard to the education of medical students and
271 residents in the principles and attributes/competencies of the PCMH.
272
273 There is an urgent need for demonstration projects that will inform both methods
274 of faculty development as well as the development of assessment tools and
275 outcomes measures.
276
277 BACKGROUND OF THE MEDICAL HOME CONCEPT
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278
279 The American Academy of Pediatrics (AAP) introduced the medical home
280 concept in 1967, initially referring to a central location for archiving a child’s
281 medical record. In its 2002 policy statement, the AAP expanded the medical
282 home concept to include these operational characteristics: accessible,
283 continuous, comprehensive, family-centered, coordinated, compassionate, and
284 culturally effective care.
285
286 The American Academy of Family Physicians (AAFP) and the American College
287 of Physicians (ACP) have since developed their own models for improving
288 patient care called the “medical home” (AAFP, 2004) or “advanced medical
289 home” (ACP, 2006).
290
291 WORKING GROUP CONTRIBUTORS
292
293 Members of the working group who volunteered their time and expertise to
294 prepare this document are listed in Appendix B.
295
296 FOR MORE INFORMATION:
297
298 American Academy of Family Physicians
299 http://www.futurefamilymed.org
300 http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html
301 http://www.transformed.com/
302 http://www.stfm.org/fmhub/fm2007/January/Ardis24.pdf
303
304 American Academy of Pediatrics:
305 http://aappolicy.aappublications.org/policy_statement/index.dtl#M
306 http://www.medicalhomeinfo.org
307 http://www.pediatricmedhome.org
308 http://www.medicalhomeinfo.org/how/performance_management.aspx
309
310 American College of Physicians
311 http://www.acponline.org/running_practice/pcmh/
312 http://www.acponline.org/advocacy/where_we_stand/medical_home/
313
314 American Osteopathic Association
315 http://www.DO-Online.org
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316 Appendix A
317 Joint Principles Mapping Grid for Educational Sub-principles Development Project
318 July 2010
319
320 Column 1 – Existing Joint Principles of the Patient Centered Medical Home
321 Column 2 – Attributes/competencies needed by physicians for medical home practice. Listed are a few examples – this will be developed by working group
322 members based on their knowledge and experience in the PCMH module and the relevant literature provided.
323 Column 3 – This is intended for listing key concepts that the working group desires to have included in the language of the educational sub-principles
324 Column 4 – This is intended to cross walk the educational sub-principles to the core competencies.
325
Joint Principle of the Attributes/Competencies Corresponding Educational Sub-principle Crosswalk to Core
PCMH Needed Competencies
Key: PC = Patient Care; MK=
Medical Knowledge; IC=
Interpersonal & Communication
Skills; P= Professionalism; PBL=
Practice-based Learning &
Improvement; SBP= Systems-based
Practice

Personal physician. Each patient • Defining and demonstrating patient- • Curriculum should provide students with longitudinal • PC, P, SBP
has an ongoing relationship with a centeredness in their clinical experience(s) in continuity relationships with patient(s) in
personal physician trained to encounters practices that deliver first-contact, comprehensive, integrated,
provide first contact, continuous • Demonstrating enhanced, timely, coordinated, high-quality and affordable care.
and comprehensive care multi-modal communications between • Curriculum should include training in communication skills with • IC, P
the practice and patients/families to patients, families and fellow professionals.
assure continuous care
• Including patients/families as
advisors to the medical home,
eliciting input and feedback on a
continuous basis

Physician-directed medical • Collaborative care • Students should experience interdisciplinary teams (i.e. • SBP, IC, P, PC
practice. The personal physician - All team members are nurses, social workers, case managers, mental health
leads a team of individuals at the accountable for their roles and professionals, diabetes educators, community partners and/or
practice level who collectively take responsibilities in delivering high- pharmacists)
responsibility for the ongoing care quality care • Students should be able to articulate the roles, functions and • SBP, P
of patients. - All team members demonstrate working relationships of all other members of the team.
respect for all other team • Curriculum should include experiences in leadership • P, PBL
members development, quality improvement, and change management.
• Team building
• Leadership skills
• Change and conflict management

Whole-person orientation. The • Life cycle knowledge/appreciation • Students should be taught to assess patient/family readiness to • MK, IC,
personal physician is responsible • Patient engagement /motivational engage in health behavior change, to promote patient self-
for providing for all the patient’s interviewing efficacy, and to facilitate health behavior change.
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health care needs or taking • Promotion of patient self-efficacy • Students should be exposed to health coaches and care • MK, SBL, IC, P
responsibility for appropriately • Promotion of shared decision-making coordinators who care for patients with complex conditions.
arranging care with other qualified • Transitions of care • Students should have opportunities to elicit from patients and/or • MK, PC
professionals. This includes for all • Promotion of health and wellbeing their families their cultural, spiritual, and ethnic values and
stages of life: acute care; chronic • Assessment of and respect for practices.
care; preventive services; and cultural values and practices • Students should be taught how to assess and accommodate to • MK, PC, IC
end-of-life care. • Assessment of health literacy diverse levels of health literacy.

Care is coordinated and/or • Effective transitions of care • Students should be exposed to the economics of health care • SBP
integrated across all elements of • Knowledge of community resources systems across a community, including all settings of care.
the complex health system (e.g. and working with non-physician • Students should learn the relationship between payment • SBP
subspecialty care, hospitals, home partners models and health care delivery models.
health agencies, nursing homes) • Use of EMRs/HIT at points of care • Students should learn the basics of medical informatics and the • MK, PBL
and the patient’s community (e.g. • Registry use technologies that support care and population management..
family, public and private • Population health • Students should be exposed to electronic health records, e- • PBL, SBP
community based services). Care • Coordination/collaboration with visits, e-prescribing and electronic billing.
is facilitated by registries, specialists, co-management of care • Students should be taught principles of population health, • MK, SBP
information technology, health over time including how patient registries can be used to manage
information exchange and other • The value of patient advocacy population health.
means to assure that patients get • Students should be taught principles of patient safety. • PBL, MK
the indicated care when and • Students should be able to assess and recommend solutions to
where they need and want it in a address patient risk during transitions of care, including use of • PBL, MK
culturally and linguistically tools such as care plans.
appropriate manner.

Quality and safety are • Use of point-of-care evidence based • Students should participate in teams within practices as they • SBP, PBL
hallmarks of the medical home: clinical decision support develop a culture of learning to improve the care process and
• Advocacy for attainment of • Interpretation of quality reports patient experience.
optimal, patient centered • Knowing principles of performance • Students should learn how health care is operationalized • SBP
outcomes defined by improvement, measurement and how outside of the hospital setting.
collaborative care planning to use information to make decisions • Students should participate in multi-disciplinary patient safety • PBL, P, MK
process within practice training experiences.
• Evidence based medicine and • Patient and family engagement • Students should have opportunities to review quality data and • PBL
clinical decision support tools • Self-assessment of one’s own recommend evidence-based systems changes to respond to
guide decision making performance performance assessment.
• Physicians accept • Knowledge of the principles of
accountability for quality community health assessment
improvement (QI) through • Patient and family advocacy skills
voluntary engagement in
performance measurement and
improvement
• Patients actively participate in
decision making and patient
feedback is sought to assure
expectations are being met
• HIT is used to support optimal
patient care performance
measurement, patient education
and enhanced communication
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• Practices go through a
voluntary recognition process to
demonstrate that they have
PCMH capabilities
• Patients and families participate
in quality improvement activities
at the practice level

Enhanced Access to care is • Understanding of rationale and • Students should experience a variety of different encounter • PC, IC
available through systems such as principles of enhanced access types provided by other team members (e.g. shadowing
open scheduling, extended hours, • Phone medicine experiences with pharmacists, nurses, social workers,
and new options for • Electronic communication schedulers and receptionists)
communications between • Group Visits • Students should experience a variety of different encounter • PC, IC
patients, their personal physician • Visits with non-physician providers types such as face-to-face, telephone and electronic
and practice staff • Care outside of the location of the messaging, and group visits
physical practice

Payment appropriately • Knowledge of elements of population- • Students should receive well-balanced instruction on physician • MK
recognizes the added value based care, non-visit work and payment methodologies that is encompassing of past, current
provided to patients who have a appreciation of value of these and future policies.
PCMH aspects of care • Students should be informed of the public and private policy • MK, SBP
• Recognizes and values work • Understanding of enhanced payment development processes that establish and/or influence
that is done outside of face- opportunities coverage and payment determinations. It is desirable that
to-face visit • Understanding and application of the students learn how they, as future physicians, can effectively
• Pays for care coordination, principles of advocacy advance those policies that are in the best interests of their
ancillary providers and patients and the nation’s health care system.
community resources • Students should be familiar with current data on the overall cost • MK, SBP
• Supports adoption of HIT for of health care. This should include an understanding of the
QI proportion of health care dollars spent on various segments of
• Supports provision of e- the health care system, those costs incurred by patients, as well
communication as the overall costs of health care for employers and the
• Recognizes values of government, and to the extent known, the relationship between
physician work associated costs and quality of care..
with remote monitoring of
clinical data using technology
• Maintains FFS
• Recognizes case mix
differences
• Allows shared savings from
reduced hospitalizations
• Allows for quality bonus or
incentive payments for
measurable improvement
326
327 *** Prerequisite to training: Faculty development is a current unmet need of this generation of faculty members, with respect to how to teach
328 medical students and residents about the PCMH – this needs attention.
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329 Working Group Contributors

330
331 Elizabeth G. Baxley, MD
332 Professor and Chair, Department of Family and Preventive Medicine
333 University of South Carolina School of Medicine
334 Columbia, SC
335
336 James Dearing, DO
337 Board of Trustees
338 American Osteopathic Association
339 Chicago, IL
340
341 Michelle Esquivel, MPH
342 Director, National Center for Medical Home Implementation
343 Director, Division of Children with Special Needs
344 American Academy of Pediatrics
345 Elk Grove Village, IL
346
347 Gary S. Fischer, MD
348 Patient Centered Medical Home Work Group
349 Society for General Internal Medicine
350 Washington, DC
351
352 Stanley M. Kozakowski, MD
353 Residency Program Director
354 Hunterdon Medical Center
355 Flemington, NJ
356
357 Shawn Martin
358 Director, Governmental Relations
359 American Osteopathic Association
360 Chicago, IL
361
362 Perry A. Pugno, MD, MPH, CPE
363 Director, Medical Education
364 American Academy of Family Physicians
365 Leawood, KS
366
367 James Swartwout
368 Associate Executive Director
369 American Osteopathic Association
370 Chicago, IL
371
372 V. Fan Tait, MD
373 Associate Executive Director
374 Director, Department of Community and Specialty Pediatrics
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375 American Academy of Pediatrics

376 Elk Gove Village, IL
377
378 Renee Turchi, MD, MPH
379 Medical Director, PA Medical Home Program
380 Drexel University School of Public Health
381 Philadelphia, PA
382
383 Sara Wallach, MD
384 Executive Council
385 Association of Program Directors in Internal Medicine
386 Washington, DC
387
388 Steven Weinberger, MD
389 Executive Vice President
390 American College of Physicians
391 Philadelphia, PA
392
393 Joseph Yasso, DO
394 Board of Trustees
395 American Osteopathic Association
396 Chicago, IL
397