A key feature of the medical home is team-based care focused on the needs of patients and, when appropriate, their family and caregivers. This type of care is centered around the whole person and includes physical, behavioral, and oral health, as well as long-term care. A patient and family-centered orientation embraces patient preferences and culture, recognizes and assists with health literacy, provides tools and resources for self-managing chronic conditions, and is founded on trust and respect between the patient and the clinician in order to develop a true partnership.
Depending on the practice, the health care team may include primary care physicians; nurse practitioners; physician assistants; mental health practitioners or behavioral health specialists; social workers; care coordinators; pharmacists; palliative care providers; physical, occupational and speech therapists; community health workers; and others who support health services in the community. The team also includes patients and their families, given that their input is the key component to realizing the medical home.
This group provides networking and educational opportunities, including expert discussions, around the integration of behavioral health within the medical home. The group has also developed screening tools to help practices identify potential Medicare reimbursements and has developed a list of resources on behavioral health integration.
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