Abstract
The patient-centered medical home (PCMH) is a team approach used to provide comprehensive care for patients in primary care settings that uses partnerships between patients and families, physicians, and other members of the healthcare team including home healthcare nurses. The goal of the PCMH model is to provide safe, high-quality, affordable, and accessible patient-centered care by promoting stronger relationships with patients, addressing care needs more comprehensively, and providing time to coordinate care across all sectors of the healthcare system. Home healthcare clinicians who have a deep understanding of the impact of community and family system interplay will have an important role in linking the home environment with the primary care based PCMH to assist patients to achieve optimal outcomes.