Evidence and Evaluation

Policy decisions concerning the PCMH must rest on sound evidence about whether this model of care helps achieve the Triple Aim of improved patient outcomes, improved patient experience, and improved value. In this section, explore information and resources for PCMH researchers, evaluators, and decision makers.

PCMH Research Methods Series

This series features research methods that can be used to evaluate and refine PCMH models and other health care interventions. Each of the briefs describes a method and how PCMH researchers have used it or could do so, discusses advantages and limitations of the methods, and provides resources for researchers to learn more about the method.

Series Overview


Anthropological Approaches
(PDF Version — 2.3MB)

Anthropology explores human culture, behavior, and expression using an ethnographic approach, which employs multiple methods of data collection to construct a holistic and contextual view of the phenomena under study. It excels in uncovering unexpected insights by studying a topic in person, in situ, over time, and from diverse perspectives. Authors: Roberta E. Goldman and Jeffrey Borkan.

Cognitive Task Analysis
(PDF Version — 2MB)

Cognitive task analysis (CTA) is a family of methods designed to reveal the thinking involved in performing tasks in real-world contexts. CTA can be used to uncover and describe key patterns, variations, opportunities for improvement, and leverage the "knowledge work" - not just the physical work - of primary care staff and clinicians implementing PCMH models. Authors: Georges Potworowski and Lee A. Green

Contextual Factors: The Importance of Considering and Reporting on Context in Research on the Patient-Centered Medical Home
(PDF Version — 403KB)

Health care and health are complex systems that are fundamentally context-dependent. What works in one context often does not work in another, which can lead to conflicting or inconsistent findings. It is important to attend to and describe contextual factors in designing, conducting, and reporting research on PCMH models. Authors: Kurt C. Stange and Russell E. Glasgow.

Efficient Orthogonal Designs
(PDF Version — 1.4MB)

Efficient orthogonal design is a tool that must be used at the outset of a study that can be used to compare the effectiveness of different ways of deploying each component of a PCMH, as well as how the effects of individual components interact with one another. Authors: Jelena Zurovac, Deborah Peikes, Aparajita Zutshi, and Randy Brown.

Formative Evaluation
(PDF Version — 813KB)

Formative evaluations provide ongoing, concrete feedback to PCMH implementers and other stakeholders on whether a model is being delivered as planned or is having the intended effects, so staff can modify the intervention as it unfolds. Authors: Kristin Geonnotti, Deborah Peikes, Winnie Wang, and Jeffrey Smith.

Implementation Research
(PDF Version — 1.2MB)

Implementation research focuses on understanding how programs are executed, translated, replicated, and disseminated in real-world settings. It expands the focus of traditional research from discovering what works to also discovering how the program works in specific contexts. Authors: Laura Damschroder, Deborah Peikes, and Dana Petersen.

Mixed Methods
(PDF Version — 1.1MB)

Mixed-methods studies systematically integrate, or "mix," quantitative and qualitative data to improve our understanding of implementation and impact findings. Authors: Jennifer Wisdom and John Creswell.

Optimal Use of Logic Models
(PDF Version — 731KB)

A logic model – also known as a program model, theory of change, or theory of action – is a graphic illustration of how a program of intervention is expected to produce desired outcomes. Logic models are not only useful for guiding data collection activities, but they are also valuable planning tools for developing strong interventions. Authors: Dana Petersen, Erin Fries Taylor, and Deborah Peikes.

Pragmatic Clinical Trials
(PDF Version — 1.6MB)

Pragmatic clinical trials (PCTs) are randomized controlled trials designed to test effectiveness in real world settings and meet the needs of stakeholders deciding whether to adopt a PCMH. In PCTs, researcher test PCMH models in typical practices and on typical patients, and evaluate a comprehensive set of outcomes related to quality, cost, and patient and provider experience. Researchers combine implementation and impact findings to distill the best approaches to a PCMH in different settings. Authors: Deborah Peikes, Kristin Geonnotti, and Winnie Wang.

Statistical Process Control
(PDF Version — 733KB)

Statistical process control is used to detect changes in process or outcome variables that are measured frequently over time. The findings are then depicted graphically to yield quick insights into the data and present them to stakeholders in a user-friendly manner. Authors: Jill A. Marsteller, Mary Margaret Huizinga, and Lisa A. Cooper.

Webinars on Methods in Delivery Systems Research

Explore slide presentations from past webinars on advanced methods in delivery system research. The webinars were sponsored by AHRQ’s Delivery System Initiative in partnership with the AHRQ PCMH program, and they include some of the following topics:

  • Fuzzy Set Analysis
  • Statistical Process Control
  • Logic Models
  • Formative Evaluation

PCMH Papers and Briefs

Explore AHRQ’s papers and briefs on PCMH research and evaluation, and developing the evidence base for the medical home model.

White Papers

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.


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.

Evaluation Tools

Get started with a guide for evaluators that presents practical steps for designing an evaluation of primary care interventions. Explore resources designed to assist researchers in evaluating crucial components of the medical home, including patient-centeredness, care coordination, the medical neighborhood, team-based care, and behavioral health integration.

Guide for Evaluators

Searchable Databases of Instruments and Measures

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.

Survey Tools


The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care

Research Articles