Patient Centered Medical Home

AHRQ Commissioned Research

New Publications

• "Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms”" Many of the goals of the PCMH rely on improved communication and coordination among health care providers and institutions. Specialists, hospitals, other providers, health plans, and other stakeholders play key roles in ensuring a close-knit and high-functioning medical neighborhood. This paper examines the various “neighbors” in the medical neighborhood and how these neighbors could work together better, thus allowing the PCMH to reach its full potential to improve patient outcomes.(PDF - 664KB) PDF Help

White Papers

• "Necessary, but not sufficient: The HITECH Act's Potential to Build Medical Homes" The recent Health Information Technology for Economic and Clinical Health (HITECH) legislation for adoption of health information technology (IT) in public insurance programs could be harnessed to help practices operationalize and implement the technology and supports key principles of the patient-centered medical home (PCMH) to improve health care quality and efficiency. While HITECH, as well as aspects of recently enacted health reform legislation, support many facets of the PCMH model, these provisions are not likely to be sufficient to drive wholesale primary care transformation. Three policy recommendations—developing PCMH-specific certification criteria for electronic health records; including PCMH functionalities in the meaningful-use concept; and extending the role of HITECH’s Regional Extension Centers to provide technical assistance to primary care providers on medical home principles—would increase the ability of health IT to support transformation by primary care practices to the PCMH model.(PDF - 236KB) PDF Help
• "Engaging Patients and Families in the Medical Home" The PCMH model provides multiple opportunities to engage patients and families within the health care system, in care for the individual patient, in practice improvement, and in policy design and implementation. This paper presents researchers and policymakers with a framework for conceptualizing these opportunities and provides insight into the evidence base for these activities, describes existing efforts, suggests key lessons for future efforts, and discusses implications for policy and research.(PDF - 571KB) PDF Help
• "Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home" Given that primary care serves as a main venue for providing mental health treatment, it is important to consider whether the adoption of the PCMH model is conducive to delivery of such treatment. This paper identifies the conceptual similarities and differences between the PCMH and current strategies used to deliver mental health treatment in primary care. Even though adoption of the PCMH has the potential to enhance delivery of mental health treatment in primary care, several programmatic and policy actions are needed to integrate high-quality mental health treatment within a PCMH.(PDF - 175KB) PDF Help
• "The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care" The effective coordination of a patient’s health care services is a key component of high-quality and efficient care. Two relatively new models in health policy—the patient-centered medical home and the Accountable Care Organization (ACO)—provide an opportunity to increase the extent and effectiveness of care coordination. The two models can work in tandem, with medical homes providing the direct coordination of services and ACOs providing the infrastructure and incentives to facilitate collaboration across different types of providers and organizations. This paper describes the central role for primary care in coordinating care, delineates the specific activities involved in care coordination and the evidence on the effectiveness of care coordination, and suggests roles for medical homes and ACOs in coordinating care.(PDF - 190KB) PDF Help

Decisionmaker Briefs

• Strategies to Ensure HITECH Supports the Patient-Centered Medical Home While the adoption and meaningful use of eletronic health records help support some aspects of the PCMH model, HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of themedical home model. This brief describes how HITECH and broader health reform legislation offer some policy options that could ensure EHRs areimplemented in a way that supports primary care transformation. (PDF - 175KB) PDF Help
• Strategies to Put Patients at the Center of Primary Care Patients’ involvement in the medical home should take place on three levels: 1) engagement in their own care, 2) quality improvement in the primary care practice, and 3) development and implementation of policy and research. This brief describes ways that decisionmakers can promote greater patient engagement at all three levels. (PDF - 185KB) PDF Help

Other Resources

• Care Coordination Measures Atlas The health care community is struggling to determine how to measure the extent to which care coordination activities are being implemented. AHRQ’s new Care Coordination Measures Atlas lists existing measures of care coordination, with a focus on ambulatory care, and presents a framework for understanding care coordination measurement. The Atlas is useful for evaluators of projects aimed at improving care coordination and for quality improvement practitioners and researchers studying care coordination. ( Care Coordination Measures Atlas)

Reports

• Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care. This report describes the concept of Practice-Based Population Health as an approach to care that uses information on a group (“population”) of patients within a primary care practice or group of practices (“practice-based”) to improve the care and clinical outcomes of patients within that practice. It also discusses the information management functionalities that may help primary care practices to move forward with this type of proactive management as well as the relationship between these functionalities and health IT certification efforts, proposed objectives for electronic health record incentive programs, and the patient-centered medical home (PCMH) model.(PDF - 236KB) PDF Help