Patient Centered Medical Home

Coordinated Care

Resources

There are tools and resources available in the Coordinated Care reference library that will provide more information about these principles.

Type	Title	Abstract	PDF	HTML
Brief	Ensuring that Patient Centered Medical Homes Effectively Serve Patients with Complex Needs	The PCMH model currently offers or coordinates many of the services required for patients with complex needs. This decisionmaker brief offers programmatic and policy changes that can help practices, especially smaller ones, better deliver services to all patients, including those with the most complex health needs.	(PDF-88.66KB) PDF Help	(Coming soon)
White Paper	Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions	Patients who have complex health needs typically require both medical and social services and support from a wide variety of providers and caregivers. This paper discusses strategies that are needed to help primary care practices perform as effective medical homes to coordinate such services for patients with complex care needs.	(PDF-91.18KB) PDF Help	(Coming soon)
White Paper	Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home	The majority of PCMH demonstrations have not explicitly addressed the integration of mental health services into primary care. This paper examines successful approaches to delivering mental health treatment in primary care and PCMH settings.	(PDF-181.16KB) PDF Help	(Coming soon)
White Paper	Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms	“Neighbors” in the medical neighborhood include the medical home, specialists, hospitals, health plans, and other stakeholders. This paper describes how these neighbors could work together better, thus allowing the medical home to reach its full potential to improve patient outcomes.	(PDF-663.28KB) PDF Help	(Coming soon)
White Paper	The Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient Care	PCMH and ACO models of care delivery can work in tandem to increase the effectiveness of care coordination. Medical homes can directly coordinate services, while ACOs can facilitate and incentivize collaboration across various providers and organizations	(PDF-340.27KB) PDF Help	(Coming soon)
Report	Care Coordination Measures Atlas	This resource 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.	(PDF-2.2MB) PDF Help	HTML