IMASEM is a PCMH Practice
The Patient-Centered Medical Home (PCMH) is an approach to providing comprehensive, continuous healthcare that is based on the foundation of a healing personal relationship between a patient, their physician, and members of the collaborative care team. Care provided through a PCMH is facilitated through partnerships between these individuals and the patients’ families. This provides a foundation in the primary care of the patients’ well being.
1. Personal Physician- Each patient will have an on going relationship with a
physician trained to provide first contact, continuous and comprehensive care.
2. A Physician directed medical practice- The personal physician will lead a team
of individuals at the practice level who will collectively take responsibility for
the ongoing care of their patients.
3. Whole person orientation- The personal physician is responsible for providing
for all the patient’s health care needs or taking responsibility for appropriately
arranging care with other qualified professionals. This includes all stages of
life: acute care; chronic care; preventive services; and end-of-life care.
4. Care is coordinated and/ or intergrated- To demonstrate the ability to
effectively call on the larger context of the health care system (e.g. hospitals,
subspecialty care, home health care agencies, nursing homes and etc.) to
provide the care that is of optimal value to the patients’ care. Understand how
to collaborate with specialists from various disciplines to provide patient-
focused co-management of care over time. Care of the patient is facilitated by
use of registries, information technology, health information exchanges and
other means to assure that the patient receives the indicated care when and
where they need it. To demonstrate sensitivity and responsiveness to a
patients’ culture, age, gender and disabilities. To take the opportunities to
elicit from patients and/or their families their cultural, spiritual, and ethical
values and practices.
5. Quality and Safety- are hallmarks of the medical home:
• Practices advocate for their patients to support the attainment of optimal,
patient-centered outcomes that are defined by a care planning process
driven by a compassionate, robust partnership between physicians, patients
and the patient's family.
• Evidence-based medicine and clinical decision-support tools guide decision
• Physicians in the practice accept accountability for continuous quality
improvement through voluntary engagement in performance measurement
• Patients actively participate in decision making and feedback is sought to
ensure patients' expectations are being met.
• Information technology (IT) is utilized appropriately to support optimal
patient care, performance measurement, patient education and enhanced
• Practices go through a voluntary recognition process by an appropriate non-
governmental entity to demonstrate that they have the capabilities to
provide patient-centered services consistent with the medical home model.
• Patients and families participate in quality improvement activities at the
6. Enhanced Access- Care is available through systems such as open scheduling,
expanded hours and new options for communication between patients, their
personal physician and practice staff.
7. Payment- Appropriately recognizes the added value provided to their patients
who have a patient centered medical home. The payment structure should be
based on the following network:
• It should reflect the value of physician and non-physician staff
patient-centered care management work that falls outside of the
• It should pay for services associated with coordination of care both
within a given practice and between consultants, ancillary
providers, and community resources.
• It should support adoption and use of health information
technology for quality improvement;
• It should support provision of enhanced communication access
such as secure e-mail and telephone consultation;
• It should recognize the value of physician work associated with
remote monitoring of clinical data using technology.
• It should allow for separate fee-for-service payments for face-toface
visits. (Payments for care management services that fall
outside of the face-to-face visit, as described above, should not
result in a reduction in the payments for face-to-face visits).
• It should recognize case mix differences in the patient population being
treated within the practice.
• It should allow physicians to share in savings from reduced
hospitalizations associated with physician-guided care
management in the office setting.
• It should allow for additional payments for achieving measurable
and continuous quality improvements.
Internal Medicine Associates of S.E. Michigan
The Internal Medicine Associates of South East Michigan (IMASEM) is a community based health care organization that caters to people from the age of 19 years old and up.
Since its foundation, the Internal Medicine Associates of S.E. Michigan has supported