Person centred care

The PCMH model is a person centred health system designed to enhance the patient experience, improve population health, reduce health care costs and foster greater satisfaction of health providers, this is known as the quadruple aim. Evaluation of the PCMH model will be based on measuring outcomes of the quadruple aim.

The quadruple aim

Improved patient experience

  • Reduced waiting times
  • Improved access
  • Patient and family needs are met
  • Safe and effective care

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Sustainable service costs

  • Efficient and effective services resulting in cost reductions of service delivery
  • Reduced potentially preventable hospital admissions
  • Ratio of funding

Quality & population health

  • Equitable access
  • Improved health outcomes
  • Reduced burden of diseases

Improved provider satisfaction

  • Improved clinician and staff satisfaction
  • Sustainable, meaningful work
  • Teamwork leadership
  • Quality improvement culture

The PCMH model of care puts the patient at the centre of their care, helping to ensure each patient has the care team they need. This person centred approach to health care incorporates 5 key attributes, designed to deliver equitable, high quality, integrated care that is accessible to all.

ART PCMH comprehensive care

Comprehensive care

This requires a team of care providers to ensure the medical needs of a person is considered as a whole.

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Person centred

PCMHs partner with patients, families and carers in the provision of care.  There is an emphasis on supporting and encouraging patient involvement and self-management.

 ART PCMH coordinated care

Coordinated care

The PCMH is responsible for coordinating patient care across the entire health system.

 ART PCMH accesible services

Accessible services

The PCMH provides accessible services including reduced waiting times, urgent access, after hours service and alternate communication methods like email or telephone.

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Quality and safety

PCMH’s are committed to continuous quality improvement using data management and eHealth technologies.

The Patient Centred Medical Home incorporates 10 building blocks deemed critical for High Performing Primary Care. You can find out more information by clicking here.

patient family carers

The persons health is managed at home by the patient, family and carers.

In patient centred care, the patient, their families and carers are at the centre of care. Ultimately it is their values, resources and actions that are the key determinants of health outcomes.

It is at home where care is most effective and optimal differences to patient outcomes occur. It also ensures that the patient and their family and carers can access the care that is needed when and where they need it.

Patient centred care carries a notion that care coordination best happens when the patient and their family or carers are empowered, willing and able to lead their own health and care choices.

COORDINARE supports patients being involved in their healthcare and has a Consumer Health Panel supporting people in the community to help shape the future of the health care system. 

medical homeThere is growing evidence that people benefit from an ongoing and consistent relationship with a trusted general practitioner.

The relationship with the GP is supported by the practice team to create the medical home team. This team can grow to include members of the broader healthcare neighbourhood as patient needs change.

COORDINARE supports general practices to manage ongoing patients and to effectively and efficiently manage patient data to set up appropriate recall systems to ensure patients visit their GP regularly when necessary. 


Peoples needs change and increase over time. As this happens the care team expands, adding new members.

The extended team may include physiotherapists, community pharmacists, psychologists, optometrists, exercise physiologists, dietitians and other allied health professionals. It may also include community nursing, home care providers and personal care providers.

The patient is treated as an informed partner in shared care decision making and the medical home serves as a gateway to specialist care across the health system, ensuring patients can access the care they need through the most efficient pathway.

An efficient healthcare neighbourhood has access to relevant patient information and the medical home is responsible for coordinating the care and also ensuring an accurate and complete clinical record for each patient.

COORDINARE offers general practices programs that support service integration including Shared Medical Appointments, Pharmacy in the Practice and GP Psychiatry Support Line.

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Patients are not transferred from one team to another, the medical home always remains a central part of their core team. As the patient’s acuity and needs increase the care team expands and as acuity diminishes or becomes better controlled the team will contract.

Creating services that sit outside the existing relationships have the potential to disrupt the system resulting in worse health outcomes. Therefore the most efficient and effective way to improve the system is by placing resources as close to the centre of the circle as possible.