The American College of Physicians has published a guide on understanding the Patient Care Medical Home (PCMH) model. Briefly, PCMH is a team-based approach and a personal physician provides care throughout a patient’s lifetime to maximize health outcomes. The PCMH team provides all of a patient’s health care needs or otherwise arranges care with other qualified professionals as needed.
http://www.acponline.org/running_practice/pcmh/understanding/what.htm
In addition, the American Academy of Family Physicians has a good visual overview of what is involved in the PCMH model and also provides a checklist available for downloading. One of the key components of PCMH is health information technology ("HIT") which includes e-mail, e-prescribing, and capture and analysis of clinical data.
http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html