Patient Centered Medical Home
The Roles of Patient-Centered Medical
Homes And Accountable Care
Organizations in Coordinating Patient Care
AHRQ Publication No.
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850, www.ahrq.gov
David Meyers, Agency for Healthcare Research and Quality; Debbie Peikes, Mathematica Policy Researcha
; Janice Genevro, Agency for Healthcare Research and Quality; Greg Peterson, Mathematica Policy Researcha
; Erin Fries Taylor, Mathematica Policy Researcha
; Tim Lake, Mathematica Policy Research a
; Kim Smith, Mathematica Policy Research; and Kevin Grumbach, University of California, San Francisco
Table of Contents
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None of the investigators has any affiliations or financial involvement that conflicts with the
material presented in this report.
This project was funded by the Agency for Healthcare Research and Quality (AHRQ), U.S.
Department of Health and Human Services. The opinions expressed in this document are those
of the authors and do not reflect the official position of AHRQ or the U.S. Department of Health
and Human Services.
Meyers D, Peikes D, Genevro J, Peterson Greg, Taylor EF, Tim Lake T, Smith K,Grumbach K.
The Roles of Patient-Centered Medical Homes and Accountable Care Organizations in
Coordinating Patient Care. AHRQ Publication No. 11-M005-EF. Rockville, MD: Agency for
Healthcare Research and Quality. December 2010.
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The effective coordination of a patient’s health care services is a key component of highquality
and efficient care. Two relatively new models in health policy—the patient-centered
medical home (PCMH) and Accountable Care Organizations (ACOs)—provide an opportunity to
increase the extent and effectiveness of care coordination in the United States. 1 (American
Academy of Family Physicians et al., 2007)
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.
For the purpose of this brief, we define care coordination as:
The deliberate organization of patient care activities between two or more participants
(including the patient) involved in a patient’s care to facilitate the appropriate delivery of
health care service. ( McDonald et al., 2007.)
Care coordination improves the quality, appropriateness, timeliness, and efficiency of clinical
decisions and care, thereby improving the quality and efficiency of health care overall.
In this brief we first describe the goals of care coordination and the central role for primary
care, followed by the specific activities involved in care coordination. Next we summarize the
evidence on the effectiveness of different care coordination activities that PCMHs and ACOs can
pursue. Finally, we suggest roles for PCMHs and ACOs in coordinating care and summarize key
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I. The Goals of Care Coordination
The two fundamental goals of care coordination are:
- To transfer information, such as medical history, medication lists, test results, and
patient preferences, appropriately from one participant in a patient’s care to another.
This includes transferring information to or from the patient.
- To establish accountability by clarifying who is responsible for each aspect of a
patient’s overall care. This includes specifying who is primarily responsible for key
care delivery activities, the extent of that responsibility, and when that responsibility
will be transferred to other care participants. The accountable entity (whether a health
care professional, care team, or health care organization) accepts responsibility for
failures in the aspect(s) of care for which it is accountable. The patient or family also
at times may be the accountable entity.
Coordination of care is one of the core functions of primary care. As conceptualized by
Barbara Starfield and the Institute of Medicine, primary care consists of providing accessible,
comprehensive, longitudinal, and coordinated care in the context of families and community.
(National Academy of Sciences, 1996.) In this model, primary care promotes cohesive care by
integrating the diverse services a patient may need. This integrative function–interpreting with
patients the meaning of many streams of information and working together with the patient to
make decisions based on the fullest understanding of this information in the context of a patient’s
values and preference–is one of the under-recognized and under-appreciated values of primary
care. Nonetheless, it is one of the main reasons that primary care contributes substantially to the
value of health care in many different health systems. (Starfield, 2005.)
Appropriate care coordination depends in large measure on the complexity of needs of each
patient or population of patients. As complexity increases, the challenges involved in facilitating
the delivery of appropriate care also increase, often exponentially. Factors that increase the
complexity of care include multiple chronic or acute physical health problems, the social
vulnerability of the patient, and a large number of providers and settings involved in a pat ient’s
care. Patients’ preferences and their abilities to organize their own care can also affect the need
for care coordination. For patients with uncomplicated care needs in ambulatory settings,
primary care physicians may be able to coordinate care effectively as part of their routine clinical
work. However, increasingly complex needs can overwhelm these informal or implicit
coordinating functions, leading to the need for a care team to explicitly and proactively
coordinate care. These teams might include individuals who specifically assume responsibility
for coordinating a patient’s care. For example, a frail elderly man with heart failure may benefit
from a nurse care manager working in concert with his primary care physician and cardiologist to coordinate services to optimize his functional status and reduce the likelihood of
Care coordination, however, is valuable for all patients, including those without complex
chronic conditions. For example, the involvement of a primary care clinician in coordinating care
for a patient with occasional migraine headaches and intermittent dyspepsia can reduce the
likelihood of the patient receiving medications that have adverse drug interactions prescribed by
different specialists focusing on each problem separately. Similarly, coordination between a
radiologist, emergency department (ED) physician, and primary care clinician can be important
in assuring appropriate followup of a worrisome incidental finding on a CT scan obtained in the
ED for an unrelated acute problem.
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II. Definitions of Care Coordination Activities1
Care coordination includes six specific activities:
1. Determine and update care coordination needs: Care coordination needs are based on a
patient’s health care needs and treatment recommendations, which reflect physical,
psychological, and social factors. Coordination needs also are determined by the patient’s current
health and health history; functional status; self-management knowledge and behaviors; and
needs for support services. The assessment of both care needs and care coordination needs
should identify the patient’s preferences and goals for health care. The assessment should be
updated periodically and after new diagnoses or other changes in health or functional status.
Needs assessment is an often overlooked foundational element in care coordination.
2. Create and update a proactive plan of care2: Establish and maintain a plan of care,
jointly created and managed by patients and their families and their health care team. The plan of
care outlines the patient’s current and long-term needs and goals for care, identifies coordination
needs, and addresses potential gaps. It also clarifies how the patient will reach the goals and who
is responsible for implementing each part of the plan (e.g. the physician, care team, or patient).
The care plan anticipates routine needs and tracks current progress toward patient goals.
3. Communicate: Exchange information, preferences, goals, and experiences among
participants in a patient’s care. Communication takes place in many forms including in person,
over the phone, and in writing, both on paper over the phone, and in writing, both on paper and electronically. It also may be done directly or
a. Between health care professionals and patients and their families: Ensure that
patients’ preferences, goals, and experiences are communicated to providers, and that
providers communicate to patients their assessment of the patient’s health needs and care
plans. Communication should be culturally and linguistically appropriate.
b. Within teams of health care professionals: Ensure that information and accountability
are explicitly exchanged among members of the patient’s care team. Professionals
should continually ask themselves, ―What do I know that others need to know?" and
share appropriate information.
c. Across health care teams or settings: While similar to communication within teams,
communication across teams and settings cannot rely on close proximity, frequent
interactions, and personal connection to assure timely transfer of information and
accountability. Timely, targeted, and formal communication systems across settings
must be built, utilized, and maintained.
4. Facilitate transitions: Share information among providers and patients when the
accountability for some aspect of a patient’s care is transferred between two or more health care
entities. Transitions require transfer of both accountability and information. This is especially
critical when care moves between distinct settings, such as during a hospital discharge. Patients
(and their families) often assume greater responsibilities during care transitions, especially when
moving from a higher to lower level of care intensity. Patients, however, generally do not assume
all responsibility for their care, and the health care providers who are assuming responsibility
need to be included in the transfer of information during transitions. Examples include transitions
from the inpatient (hospital) or skilled nursing facility setting to the ambulatory setting (i.e.,
physician’s office), as well as transitions from acute episodes of care to chronic disease
5. Connect with community resources: Provide, and if necessary, coordinate services with
additional resources available in the community that help support patients’ health and wellness
or meet their care goals. Community resources are any service or program outside the health care
system that may support a patient’s health and wellness. These include financial resources (e.g.,
Medicaid, food stamps), social services, educational resources, accessible schools for pediatric
patients, support groups, or support programs (e.g., Meals on Wheels).
6. Align resources with population needs: At a system-level, assess the needs of
populations to identify and address gaps in services. Aggregating the needs assessments of individual patients is one method that should be used to identify the population’s needs. Care
coordination and feedback from providers and patients should also be used to identify
opportunities for improvement. Examples of such population health coordination might be
identifying clusters of patients who smoke and offering smoking cessation programs in those
neighborhoods and identifying long wait times for specific subspecialty consultations and
designing electronic referral systems that reduce referral delays.
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III. Summary of Evidence from Care Coordination
A review of existing evidence on care coordination suggests that some approaches work
while others are not effective. We note that almost all models do not test the effects of care
coordination in isolation, but rather in combination with some direct clinical services.
- Primary care, defined as coordinated comprehensive first contact care, is strongly
associated with improved health and health system functioning. (Starfield, 2005.)
- o Recent comprehensive efforts to strengthen primary care, including implementation
of the PCMH model, which includes an emphasis on the core coordinating functions
of primary care, are demonstrating improved patient experience, improved staff
experience, improved quality, and reduced ED and hospital utilization. (Reid et al.
2010; Paulus et al. 2008.)
- Well-designed, targeted care coordination interventions delivered to the right people
can improve patient, provider, and payer outcomes.
- o Some models that combined care coordination and care have improved health
outcomes and/or reduced hospitalizations, readmissions, and/or costs. (Paulus et al.
2008; Friedberg et al. 2009; Reid et al. 2009, 2010; Dorr et al. 2008; Leff et al. 2009;
Counsell et al. 2007, 2009; Naylor et al. 2004; Coleman et al. 2006; Jack et al. 2009;
Peikes et al. 2009.) Not all programs have been shown to be effective. (CMS 2008;
McCall et al. 2008; Chen et al. 2007; Peikes et al. 2009.) Among effective programs,
effects on hospitalization rates range from 8% to 46% reductions. Most have been
determined to be effective only for high risk patients. (Peikes et al. 2009; Dorr et al.
2008; Leff et al. 2009; Counsell et al. 2007, 2009; Naylor et al. 2004; Coleman et al.
2006; Jack et al. 2009.)
- Targeted care coordination can be effective in several different settings.
- o Some successful models of targeted care coordination have been embedded in
primary care offices. (Paulus et al. 2008; Friedberg et al. 2009; Reid et al. 2010;
Dorr et al. 2008; Leff et al. 2009; Counsell et al. 2007, 2009.)
- o Other successful models of targeted care coordination have been administered
outside the primary care practice but have built strong, personal links with the
staff of primary care and specialty care offices. (Naylor et al. 2004; Coleman et al.
2006; Jack et al. 2009; Peikes et al. 2009.)
- o Some transitional care interventions have demonstrated positive results by using a
targeted form of care coordination to empower and inform patients and families
during the period of transition without directly engaging clinical care providers.
(Naylor et al. 2004; Coleman et al. 2006; Jack et al. 2009.)
- Most successful models of care coordination have incorporated some (and often a
high degree of) face-to-face interaction between patients and care coordinators to
establish and maintain personal relationships.
- Almost all successful models of targeted care coordination have incorporated some
face-to-face interaction between the designated care coordinators and clinicians.
- Targeted care coordination interventions are frequently most successful (or only
successful) for high-risk/high need patients.
What Has Not Worked
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- Disease management services provided primarily by telephone have not been
effective for Medicare beneficiaries.
- Targeted care coordination services provided to low-risk Medicare patients have not
been shown to improve the quality or utilization of care and at times have increased
- Patient enrollment and participation in targeted care coordination programs have been
challenging to achieve. Support by the patient’s existing providers has helped
IV. Suggested Roles of Medical Homes and ACOs in
Coordinating Patient Care
From the vantage point of the PCMH, care coordination is a core activity. Through proactive
care teams, primary care medical homes can both coordinate care with and for patients and use
the results of good care coordination to develop appropriate care plans. For most patients in a
primary care practice, the medical home team – which might include nurses, pharmacists, nurse
practitioners, physicians, physician assistants, medical assistants, educators, behavioralists, social
workers, care coordinators, and others – will take the lead in working with the patient to define
care needs and to develop and update a plan of care. The PCMH team is also responsible for
assuring communication with patients and their families and across the primary care team. The
PCMH is responsible for partnering with professionals and teams in other settings that
participate in a given patient’s care including at times of care transitions. The PCMH should also
be involved in connecting with community resources and aligning resources, although these
functions may be led by or supported by other providers external to the PCMH.
It is critical that PCMHs have the resources needed to accomplish care coordination
activities. Traditional fee-for-service reimbursement schemes that pay only for face-to-face visits
with primary care professionals undermine the provision of care coordination services, especially
for complex patients. A recent study of high-functioning primary care practices found that in
addition to seeing an average of 18 patients, physicians also handle an average of 24 telephone
calls, 17 emails, 12 prescription refills, and 45 reviews of laboratory, imaging, or consultation
reports per day. (Baron 2010.) Requiring additional activities without compensation is unlikely
to result in increased care coordination.
From the vantage point of an ACO, coordination of care is critical to achieving the dual goals
of high-quality and high-value care. Building on the care coordination efforts of PCMHs, ACOs
can ensure and incentivize communications among teams of providers operating in varied
settings. Additionally, ACOs can facilitate transitions and align resources to meet the clinical
care and care coordination needs of populations. This work includes and extends beyond creating
hospital discharge care coordination programs to creating a ―medical neighborhood‖ where
providers share information with one another. Recognizing that, at times, primary responsibility
for care coordination for specific patients, including assessing needs and developing a care plan,
may be assigned to non-primary care specialty teams (for example, when patients are receiving a
complex set of services for a particular disease, such as cancer or severe mental illness), ACOs
can ensure that these transitions of accountability happen and that specialty teams are ready,
willing, and able to provide these services. ACOs can also develop and support systems for care
coordination for patients who reside in non-ambulatory care settings. Health information
technology (Health IT) systems also are critical for the successful transfer of information. These systems, when used appropriately, can play a critical role in establishing and monitoring
accountability. For example, an ACO could use Health IT to monitor the timeliness and
completeness of information flows between primary care providers and specialists, and use the tracking
information to incentivize high levels of responsiveness and collaboration.
Bringing the PCMH and ACO Perspectives Together. A concept that bridges the PCMH
and ACO perspectives on care coordination is ―integrated care.‖ As articulated by Anne Beal and
the Aetna Foundation, ―Integrated health care starts with good primary care and refers to the
delivery of comprehensive health care services that are well coordinated with good
communication among providers; includes informed and involved patients; and leads to highquality,
cost-effective care. At the center of integrated health care delivery is a high-performing
primary care provider who can serve as a medical home for patients.‖ (Aetna Foundation 2010.)
As this definition indicates, a well-functioning patient-centered medical home is a necessary
component of integrated care—but it is not sufficient. True integration also requires the type of
cohesive medical neighborhood that is envisioned as a product of ACOs.
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- Care coordination is an essential function of primary care and the PCMH.
- PCMHs require additional resources for care coordination. Health IT, appropriatelytrained
staff for team-based models of care coordination, and payment models that
compensate PCMHs for the effort devoted to care coordination activities that fall outside
the in-person patient visit may help to encourage coordination.
- o Current fee-for-service based reimbursement systems are not adequate to support care
coordination functions in primary care and in fact disincentivize needed investments
- While all patients have care coordination needs and benefit from receiving appropriate
coordination and the resulting improved care management, patients with complex health
needs will benefit the most from care coordination.
- o Patient assessments should guide more intensive and personalized services to those
with the greatest needs.
- Patients with conditions requiring complex care from multiple providers often need enhanced
coordination of services. These enhanced services may require the support of skilled care
coordinators who work closely with patients, families, and clinicians.
- o Evidence suggests that care coordinators should be supported in having some face-toface
contact with patients in order to build trusting relationships.
- o Comprehensive care coordinators can be integrated into PCMH primary care teams; if
they operate in community settings outside of the PCMH office, coordinators must
develop close and strong relationships with health professionals and teams.
- o In addition to primary care-based care coordination, ACOs should develop additional
care coordination programs for other settings including hospitals.
- The structures and functions of ACOs allow them to ensure high-quality care coordination by
incentivizing both cooperation across care teams and settings and the transfer of
accountability and information. Additionally, ACOs are well suited to aligning resources to
meet population care coordination needs.
- Care coordination interventions, both in PCMHs and ACOs, should be designed to reflect the
strengths and needs of local communities.
- Multiple models of care coordination are likely to be effective. To promote learning and
quality improvement, care coordination efforts in PCMHs and ACOs should be evaluated
and the results shared widely.
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- a. The work of these authors was supported under Contract Number HHSA290200900191TO2 to Mathematica Policy Research.a
- 1. While the specific concept of the PCMH is relatively new, the idea of the medical home was developed more than 40 years ago in the field of pediatrics (American Academy of Family Physicians et al. 2007)1
- 2. Definition adapted from McDonald, et al, Care Coordination Measures Atlas, Agency for Healthcare Research and Quality, Forthcoming.2
- 3. Definition adapted from Brown et al. 2004.3