5 Key Functions of the Medical Home

The medical home encompasses five functions and attributes. This page includes white papers and briefs related to each area.

Comprehensive Care

The PCMH is designed to meet the majority of a patient’s physical and mental health care needs through a team-based approach to care.

Briefs

White Papers

Research Articles

View search articles about PCMH and Comprehensive Care in our Citations Collection.

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Patient-Centered Care

The PCMH delivers primary care that is oriented towards the whole person. This can be achieved by partnering with patients and families through an understanding of and respect for culture, unique needs, preferences, and values.

Toolkit

Health Literacy Universal Precautions Toolkit
(PDF Version — 4.2MB)
The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.

Related Resources:

  • Companion Implementation Guide
    (PDF Version — 404KB)
    "Implementing the AHRQ Health Literacy Universal Precautions Toolkit: Practical Ideas for Primary Care Practices" is must-read for health literacy team leaders, practice facilitators, and quality improvement leaders. Based on the experience of diverse primary care practices, the guide supplements the toolkit by providing lessons learned in the course of implementing health literacy tools.
  • Using Health Literacy Tools to Meet PCMH Standards
    (PDF Version — 347KB)
    This crosswalk identifies tools from the AHRQ Health Literacy Universal Precautions Toolkit that can be used to meet specific NCQA, The Joint Commission, and URAC PCMH standards.

Briefs

White Papers

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.

Creating Patient-centered Team-based Primary Care
(PDF Version — 971KB)
Well-implemented team-based care has the potential to improve the overall quality and comprehensiveness of primary care. However, team-based approaches also may disrupt or change specific aspects of care, such as ongoing relationships, that are important to patients and providers. This paper offers a conceptual model and specific strategies to help primary care practices successfully transition to patient-centered team-based care.

Research Articles

View search results for PCMH and Patient-Centered Care in our Citations Collection.

Search the Citations Collection: Patient-Centered Care

Coordinated Care

The PCMH coordinates patient care across all elements of the health care system, such as specialty care, hospitals, home health care, and community services, with an emphasis on efficient care transitions.

Briefs

White Papers

Reports

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.

Care Coordination Measures Atlas
(PDF Version — 2.8MB)
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. The latest version of the Atlas was updated in June 2014.

Research Articles

View search results for PCMH and Coordinated Care in our Citations Collection.

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Accessible Services

The PCMH seeks to make primary care accessible through minimizing wait times, enhanced office hours, and after-hours access to providers through alternative methods such as telephone or email.

Research Articles

View search results for PCMH and Accessible Services in our Citations Collection.

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Quality & Safety

The PCMH model is committed to providing safe, high-quality care through clinical decision-support tools, evidence-based care, shared decision-making, performance measurement, and population health management. Sharing quality data and improvement activities also contribute to a systems-level commitment to quality.

White Papers

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.

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.

Briefs

Research Articles

View search results for PCMH and System Approach to Quality & Safety in our Citations Collection.

Search the Citations Collection: Quality & Safety