All Papers, Briefs, and Other Resources on the PCMH

Ensuring that Patient Centered Medical Homes Effectively Serve Patients with Complex Needs
(PDF Version — 88KB)
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

Improving Evaluations of the Medical Home
(PDF Version — 88KB)
A concise description for decisionmakers of why and how to commission effective evaluations of medical home demonstrations. Learn what outcomes to assess, why to include control practices, and why not accounting for clustering can doom an evaluation.

The Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary Care
(PDF Version — 106KB)
The PCMH must fully engage patients to achieve its objectives, and this brief describes how decisionmakers can encourage a model of care that truly reflects the needs, preferences, and goals of patients and families.

Strategies to Ensure HITECH Supports the Patient Centered Medical Home HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of the medical home model
(PDF Version — 175KB)
HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of the medical home model. This brief discusses the ways in which HITECH and broader health reform legislation could ensure EHRs are implemented in a way that supports primary care transformation.

Building Capacity for Primary Care Quality Improvement
These briefs describe the need for external infrastructure to help primary care practices develop quality improvement (QI) capacity and describe approaches and supports for ongoing QI.

• Decisionmaker Brief: Primary Care Quality Improvement No. 1 - Creating Capacity for Improvement in Primary Care: The Case for Developing a Quality Improvement Infrastructure
  (PDF Version — 251KB)
• Decisionmaker Brief: Primary Care Quality Improvement No. 2 - Building Quality Improvement Capacity in Primary Care: Supports and Resources
  (PDF Version — 1.6MB)

PCMH Research Methods Series
A series of briefs to "expand the toolbox" of evaluation methods. Access the full PCMH Research Methods Series from the Evidence and Evaluation page.

Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers
(PDF Version — 84KB)

Efforts to redesign primary care require multiple supports. Two potential members of the primary care team—practice facilitator and care manager—can play important but distinct roles in redesigning and improving care delivery.

Early Evidence on Patient-Centered Medical Home
(PDF Version — 201KB)

The patient-centered medical home (PCMH, or medical home) aims to reinvigorate primary care and achieve the triple aim of better quality, lower costs, and improved experience of care. This study systematically reviews the early evidence on effectiveness of the PCMH.

Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions
(PDF Version — 91.18KB)
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.

Building the Evidence Base for the Medical Home: What Sample and Sample Size Do Studies Need?
(PDF Version — 368KB)

Evaluations of the medical home should account for clustering of patients within practices. This paper describes why and how to do this and what samples of patients and practices are needed for studies to achieve adequate statistical power.

Engaging Patients and Families in the Medical Home
(PDF Version — 526.27KB)
A key element of the PCMH model is engaging patients and caregivers in their care. This paper offers policymakers and researchers insights into opportunities to engage patients and families in the medical home and includes a framework for conceptualizing opportunities for engagement. It also reviews the evidence base for these activities, and offers examples of existing efforts as well as implications for policy and research.

Necessary But Not Sufficient: The HITECH Act and Health Information Technology’s Potential to Build Medical Homes
(PDF Version — 175KB)
HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of the medical home model. This brief discusses the ways in which HITECH and broader health reform legislation could ensure EHRs are implemented in a way that supports primary care transformation.

Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms
(PDF Version — 663.28KB)

“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.

Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home
(PDF Version — 181.16KB)
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.

Engaging Primary Care Practices in Quality Improvement: Strategies for Practice Facilitators
(PDF Version — 1MB)
This white paper describes approaches practice facilitators can take for encouraging primary care practices to undertake quality improvement (QI) activities. It presents a framework for engaging primary care practices in QI and provides practical strategies for gaining initial buy-in from practices, maintaining meaningful and sustained engagement in QI efforts, and working with multiple QI programs.

The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in Coordinating Patient Care
(PDF Version — 340.27KB)
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.

Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care
(PDF Version — 752KB)
Practice-Based Population Health is an approach to care that uses information on a group of patients within a primary care practice(s) to improve the care and clinical outcomes of patients within that practice. This report describes this approach and discusses the information management functionalities that may help primary care practices to move forward with this type of proactive management.

Care Coordination Accountability Measures for Primary Care Practice
(PDF Version — 300.88KB)
This resource was developed in response to the need for measures for assessing or recognizing care coordination as it is carried out by primary care practices. The report lists care coordination measures selected systematically from AHRQ’s Care Coordination Measures Atlas (see above) that are well suited for use by health plans and insurers to assess the quality of care coordination in primary care practices and by primary care practices themselves to assess their own performance.

Primary Care Measures Databases: Resources for Research and Evaluation

Are you looking for instruments and measures to study and evaluate interventions to improve primary care? Use these searchable databases to explore frameworks for measurement, and to identify and compare measures within 4 areas that are critical to primary care improvement. For each database, there is a companion Atlas report available.

1. Care Coordination Measures Database
(PDF Version — 2.2MB)

Care coordination is considered a core function in the provision of patient-centered, high-value, high-quality primary care. However, challenges remain in measuring the structural and process aspects of care coordination, as well as its contributions to desired outcomes. The Care Coordination Measures Database (CCMD) is designed to assist evaluators and researchers by providing comprehensive profiles of existing measures of care coordination; organizing those measures along two dimensions (domain and perspective); and presenting a framework for understanding care coordination measurement, to which the measures are mapped. This framework incorporates elements from other proposed care coordination frameworks and is designed to support development of the field. Users of the CCMD can compare more than 90 validated care coordination measurement tools to identify and select those that are most appropriate for their research and evaluation needs.

2. Clinical-Community Relationships Measures Database
(PDF Version — 1.88MB)

Understanding primary care's role in the medical neighborhood and in improving population health, as well as the health of individual patients, is an increasingly important aspect of primary care transformation. Relationships among patients, primary care clinics/clinicians, and community resources can be measured. However this has been an understudied aspect of primary care services. In the context of the Clinical-Community Relationships Measures Database (CCRM Database), a clinical-community relationship exists when a primary care clinician makes a connection with a community resource to provide certain preventive services such as tobacco screening and counseling. The clinical practice and the community resource may engage by networking, coordinating, cooperating, or collaborating. The CCRM Database provides a framework for understanding the measurement of clinical-community relationships and provides information about existing measures, as well as links to resources to improve CCRM research and implementation.

3. Team-Based Primary Care Measures Database
(PDF Version — 857KB)

Successful primary care redesign efforts such as the Patient-centered Medical Home require a high-functioning primary care team that delivers team-based care. Team-based primary care holds promise as a way to improve patient outcomes, care processes, and patient and provider experiences of care. However, a better understanding of how teams should function is needed, which in turn requires a strong theoretical conceptual framework and validated measures, specific to and appropriate for use in the primary care setting. Having robust measures of team-based care appropriate to the primary care setting is critical to evaluating and improving team function and patient outcomes. The Team-based Care Measures Database is an inventory of instruments that provides a conceptual framework for team-based primary care and profiles of over 40 instruments for use in research and evaluation.

4. Atlas of Integrated Behavioral Health Care Quality Measures
(PDF Version — 368KB)

Integrated behavioral health care can systematically enhance the ability of primary care practices to address behavioral health issues that naturally emerge in the primary care setting, prevent fragmentation between behavioral health and medical care, and create effective relationships with mental health specialists. As greater numbers of practices and health systems begin to design and implement integrated behavioral health services, there is a growing need for quality measures that are rigorous and appropriate to the specific characteristics of different approaches to integration. The IBHC Measures Atlas supports the field of integrated behavioral health care measurement by presenting a framework for understanding measurement of integrated care; providing a list of existing measures relevant to integrated behavioral health care; and organizing the measures by the framework and by user goals to facilitate selection of measures.

A How-To Guide on Developing and Running a Practice Facilitation Program
(PDF Version — 2.9MB)
This how-to guide is for organizations interested in starting a practice facilitation program aimed at improving primary care. The practice facilitation programs described in this guide are designed to work with primary care practices on quality improvement activities, with an emphasis on primary care redesign and transformation. The guide focuses on how to establish and run an effective practice facilitation program, and is intended for organizations or individuals who will develop, design, and administer such programs.

This guide was developed based on information and resources shared by more than 30 experts in the field of practice facilitation. AHRQ convened the expert working group through a series of webinars and conference calls over a nine month period in 2011. These experts provided practical knowledge and hard-won lessons from their experiences in practice facilitation, and shared resources that they developed or found useful.

Topics covered in the guide include:

• Background and existing evidence for practice facilitation
• Creating the administrative foundation for your practice facilitation program
• Funding your practice facilitation program
• Developing your practice facilitation approach
• Hiring your practice facilitators
• Training your practice facilitators
• Supervising and supporting your practice facilitators
• Evaluating the quality and outcomes of your practice facilitation program

In addition, the guide includes an extensive collection of tools and links to resources relevant to the development, operation and maintenance of your practice facilitation program.

How a Practice Facilitator Can Support Your Practice
(PDF Version — 85KB)
This document provides tips and techniques for engaging in QI activities in your practice.

The Citations Collection is searchable database contains over 800 citations, including journal articles, reports, policy briefs, and newsletters. Users can search by topic, population, keyword, or bibliographical data.

Search the Citations Collection

AHRQ’s Primary Care Practice Facilitation Curriculum is designed to assist in the training of new practice facilitators as they begin to develop the knowledge and skills needed to support meaningful improvement in primary care practices.

Explore the curriculum >>

In December 2011, AHRQ published a how-to manual on practice facilitation titled Developing and Running a Practice Facilitation Program for Primary Care Transformation: A How-To Guide. In conjunction with the release of this manual, AHRQ also created a Primary Care Practice Facilitation (PCPF) learning community. As a part of this learning community, AHRQ hosted a series of webinars on practice facilitation, all of which are outlined on the Webinars page.

Go to Webinars page >>

Overview
This brief summary highlights characteristics of three exemplar Primary Care Practice Facilitation (PCPF) training programs that are featured in this section as individual case studies. Case studies include information about the program's background, design, course components, trainees, faculty, process for internal quality improvement, outcomes, and administration. Lessons learned and next steps for the program are described also.

HealthTeamWorks' Coach University
This case study features one of the country's leading medical practice coach training programs that convene groups of trainees for a weeklong educational program, or "boot camp," to teach knowledge and skills for successful practice facilitation. After attending boot camp in Colorado, trainees are provided support throughout the next year as part of the program's collaborative coaching model.

Millard Fillmore College Practice Facilitator Certificate Program
This case study describes an online distance-learning course that teaches core competencies of practice facilitation work, as well as specialized skills facilitators will need when working with a medical practice. The program's online format includes seminars and virtual group discussions to encourage participants to leverage each other’s expertise.

Practice Coach Training for the North Carolina AHEC Practice Support Program
This case study features a training program in North Carolina that prepares practice coaches to serve on regional practice facilitation teams. These teams work with primary care practices to improve quality of care, transform to patient-centered medical homes, implement electronic health records, and attain meaningful use certification.

For more case studies on practice facilitation programs and lessons learned from the field, visit the Case studies section of the Practice Facilitation page.

For information on evaluating primary care interventions, visit the Evaluation Tools section of the Evidence and Evaluation page