Patient Centered Medical Home

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Papers, Briefs, and Other Resources

Explore all of the briefs, papers, and resources that AHRQ has developed for various stakeholders interested in learning more about the medical home.

TypeTitleAbstractPDFHTML
PaperEnhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care ManagersEfforts 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.(PDF-84KB)
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BriefEnsuring that Patient Centered Medical Homes Effectively Serve Patients with Complex NeedsThe 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-175.75KB)
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BriefImproving Evaluations of the Medical HomeA 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.(PDF-88.66KB)
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BriefThe Patient-Centered Medical Home: Strategies to Put Patients at the Center of Primary CareThe 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.(PDF-106.34KB)
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BriefStrategies to Ensure HITECH Supports the Patient Centered Medical HomeHITECH 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.(PDF-91.18KB)
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White PaperEarly Evidence on Patient-Centered Medical HomeThe 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.(PDF-201.18KB)
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White PaperCoordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and SolutionsPatients 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)
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White PaperBuilding the Evidence Base for the Medical Home: What Sample and Sample Size Do Studies Need?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.(PDF-368.48KB)
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White PaperEngaging Patients and Families in the Medical HomeA 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.(PDF-526.27KB)
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White PaperNecessary But Not Sufficient: The HITECH Act and Health Information Technology’s Potential to Build Medical HomesThe HITECH legislation could help to support key principles of the PCMH through the adoption of health IT. This paper discusses how the legislation can support these principles, as well as policy recommendations that would increase the ability of health IT to support primary care transformation in the future.(PDF-302.88KB)
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White PaperCoordinating 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)
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White PaperIntegrating Mental Health and Substance Use Treatment in the Patient-Centered Medical HomeThe 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)
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ReportThe Roles of Patient-Centered Medical Homes And Accountable Care Organizations in Coordinating Patient CarePCMH 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)
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ReportPractice-Based Population Health: Information Technology to Support Transformation to Proactive Primary CarePractice-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.(PDF-752.49KB)
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ReportCare Coordination Accountability Measures for Primary Care PracticeThis 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.(PDF-300.88KB)
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ReportCare Coordination Measures AtlasThis 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)
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ManualDeveloping and Running a Practice Facilitation Program for Primary Care Transformation: A How-To GuidePractice facilitation is increasingly considered a promising means for improving primary care. This guide provides information on how to start and run a facilitation program to work with primary care practices on quality improvement activities, particularly those oriented toward primary care redesign and transformation.
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CatalogCatalog of Federal PCMH ActivitiesThis resource summarizes PCMH-related work of Departments and Agencies participating in a Federal PCMH Collaborative, including AHRQ, DOD, HRSA, NIH/NCI, SAMHSA, and the VA. HTML
Citations DatabasePCMH Citations CollectionThis searchable database contains over 800 citations, including journal articles, reports, policy briefs, and newsletters. Users can search by topic, population, keyword, or bibliographical data. HTML