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Primary Care Medical Home (PCMH) - Physician Requirements for the Interdisciplinary Team

What are the practitioner requirements for PCMH certified programs?

Any examples are for illustrative purposes only.

The team must include a doctor of medicine or doctor of osteopathy. Physician participation on interdisciplinary teams may be obtained either through an employment or referral relationship such as a contract.  The intent of this requirement is that while a Doctor of Medicine or doctor of osteopathy is always available to be part of the interdisciplinary team, his or her involvement in a patient's care would be determined by the needs of the patient.  

Physical Presence 
There is no expectation that physicians or any other individuals participating on a patient's interdisciplinary team be physically present in the PCMH or interact with the patient at each encounter. Although some PCMHs may bring together large and diverse interdisciplinary teams to meet the needs of their patients, many others, such as smaller rural organizations may choose to establish virtual teams using telehealth communication processes. For example, a cardiologist might be included on interdisciplinary team of a patient with heart disease or an endocrinologist on the interdisciplinary team of a diabetic patient. 

Advance Practice Nurses
The Joint Commission does certify PCMHs that are led by advanced practice nurses serving as primary care clinicians. The standards do not impose any additional restrictions on the scope of practice of individuals qualified to serve as primary care clinicians (PCC). 

Supervision or Collaborative Agreement Requirements
PCMH standards do not require physician supervision over advance practice nurses or formal collaborative agreements between the two groups if it is not required by state law. If physician supervision or a formal collaborative agreement is required by state law, then the surveyors would expect to see evidence of that supervision. It is expected that advanced practice nurses serving in the role of primary care clinicians (PCC) will continue to collaborate with physicians as needed, to meet the needs of the patients on their panels.
NOTE: The term "collaboration" in this context means that health care providers work together to meet the needs of the patient. It is not the intent of this requirement to impose additional restrictions on the scope of practice of an advanced practice nurse, nor is it meant to preempt applicable state law.
Last updated on March 03, 2021
Manual: Critical Access Hospital
Chapter: Leadership LD

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