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Medical Home Model

Quick Reference

  • This flyer explains the idea of a Medical Home.


  • Watch this video in Spanish here.

What Is a Medical Home?

A Medical Home is:
  • A concept of quality healthcare, not a building, house or hospital
  • A team approach to coordinating healthcare services
  • Promotes a partnership between the patient, families and providers
  • Encompasses medical, mental, and oral healthcare
  • When care and treatment options are mutually discussed and collaboratively decided
  • Accomplished when patients and families feel included and valued
The Medical Home Model is an approach to healthcare that ensures that all providers of a patient’s care operate as a team, that families are critical members of that team, and that all team members understand the importance of quality coordinated medical and mental healthcare.

When a patient is enrolled with a Medical Home practice, they are expected to have a usual source of care involving a primary care medical provider. The care should be patient and family centered. Referrals and care coordination must be easily accessible if needed.

What are the Medical Home Model Principles?

The care provided is:
  • Patient/family-centered
  • Whole-person oriented and comprehensive
  • Coordinated and integrated
  • Provided in partnership with the patient and promotes self-management
  • Outcomes-focused
  • Consistently provided by the same provider as often as possible so a trusting relationship can develop
  • Provided in a culturally competent and linguistically sensitive manner

A Primary Care Medical Provider (PCMP) that is:
  • Accessible, aiming to meet high access-to-care standards such as 24/7 phone coverage with access to a clinician that can triage; extended daytime and weekend hours; appointment scheduling within 48 hours for urgent care,10 days for symptomatic, non-urgent care, and 45 days for non-symptomatic routine care; and short waiting times in reception area
  • Committed to operational and fiscal efficiency
  • Able and willing to coordinate with its associated RCCO on medical management, care coordination, and case management of patients
  • Committed to initiating and tracking continuous performance and process improvement activities, such as improving tracking and follow-up on diagnostic tests, improving care transitions, and improving care coordination with specialists and other Medicaid providers, etc.
  • Willing to use proven practice and process improvement tools (assessments, visit agendas, screenings, patient self-management tools and plans, etc.)
  • Willing to spend the time to teach patients about their health conditions and the appropriate use of the healthcare system as well as inspire confidence and empowerment in patients’ healthcare ownership
  • Focused on fostering a culture of constant improvement and continuous learning
  • Willing to accept accountability for outcomes and the patient/family experience
  • Able to give patients and designated family members easy access to their medical records when requested
  • Committed to working as a partner with the RCCO in providing the highest level of care to patients

You can also visit the Colorado Medical Home Initiative webpage for more information.