Table 1.

Responsibilities of Medical Homes, Patients, and Medical Neighbors

Medical home	Patient	Medical neighbor
• Provides first-contact, longitudinal, and whole-person care	• Seeks first-contact, longitudinal, and whole person care from medical home	• Redirects patients seeking first-contact, longitudinal, whole-person care to MH
• Gathers information on patient’s priorities and preferences on a continuous basis	• Explains priorities and preferences completely and honestly, and informs all clinicians if/when they change	• Gathers information on patient’s priorities and preferences on a continuous basis
• Ensures that patients and caregivers understand care options	• Engages caregivers in learning about care options and alerts clinicians when they don’t understand information on care options	• Ensures that patients and caregivers understand care options
• Engages in shared decision-making with patients, caregivers, neighbors on broad care options and in order to develop a longer term care plan	• Engages in shared decision-making with medical home and neighbors on particular care options and in order to develop a longer term care plan	• Engages in shared decision-making with patients, caregivers, and medical home on care options specific to neighbor services, and to develop a longer term care plan
• Arranges for services from neighbors	• Tells medical home whether they actually received services from neighbors and when they self-refer for care from other providers	• Coordinates with medical home to arrange for services from other neighbors and encourages patients to follow-up with medical home
• Summarizes and transits clinical and other patient information to neighbors before patient’s arrival for neighbor services	• Summarizes and transits clinical and other patient information to neighbors and MH before or at point of care	• Receives and synthesizes clinical and other patient information from medical home. Tells medical home and patient when transmitted information is insufficient
• Receives and synthesizes clinical and other patient information from neighbors. Tells neighbors and patient when transmitted information is insufficient	• Tells medical home and neighbors when transmitted information is insufficient	• Summarizes and transits clinical and other patient information to medical home before patient’s arrival for medical home follow-up
• Directly communicates with patient and neighbors about the rationales for clinical recommendations	• Alerts medical home and neighbors when they don’t understand the rationales for clinical recommendations	• Directly communicates with patient and medical home about the rationales for clinical recommendations
• Tracks the occurrence and results of referrals and treatments and institutes processes for ensuring their completion	• Tracks the occurrence and results of referrals and treatments	• Tracks the occurrence and results of referrals and treatments and institutes processes for ensuring their completion
• Communicate their assessment of care quality, including coordination actions by neighbors (may be based on data from other parties such as insurers), to patients and neighbors	Communicate their assessment of the quality of care to medical homes and neighbors	• Communicate their assessment of the quality of care, including quality of coordination actions by medical homes, to patients and medical homes
• Engage in quality improvement with patients and neighbors		• Engage in systematic quality improvement with patients and medical home