Table 1. Elements of the Patient-Centered Medical Home (PCMH) at Pathways to Housing-PA (PTH-PA)14
Personal physician25% of PTH-PA clients have the on-site family physician as their PCP. Efforts are ongoing to link all clients with a PCP either on site or in the community because almost 50% of clients do not have a known PCP.
Physician-directed medical practiceA family physician is the medical director of PTH-PA.
Whole-person orientationPTH-PA offers fully integrated primary and behavioral health care. The principles of mental health recovery are a core value.
Care is coordinated and integrated across all elements of the complex health care systemAll care transitions are coordinated closely by the PTH-PA staff. On-site meetings frequently occur between PTH-PA staff and the staff of outside care facilities.
Quality and safetyPTH- PA has developed the infrastructure for ongoing continuous quality improvement. Clients actively participate through community-based participatory research and a consumer health advisory board.
Enhanced accessAppointment scheduling is open access and staff is available 24 hours a day.
PaymentPayment for family physician time is not built into the behavioral health billing structure. Payment relies on contracts and in-kind support.
  • PCP, primary care physician.