The Medical Home: What Do We Know, What Do We Need to Know? A Review of the Earliest Evidence on the Effectiveness of the Patient-Centered Medical Home Model

March 2013
AHRQ Publication No. 12(14)-0020-1-EF
Prepared For:
Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850,

Contract Numbers: HHSA290200900019I/HHSA29032002T, HHSA290200900019I/HHSA29032005T
Prepared By: Mathematica Policy Research, Princeton, NJ; Aparajita Zutshi, Ph.D., Deborah Peikes, Ph.D., M.P.A., Kimberly Smith, Ph.D., M.P.A., Melissa Azur, Ph.D. (Mathematica Policy Research),  Janice Genevro, Ph.D., Michael Parchman, M.D., David Meyers, M.D. (Agency for Healthcare Research and Quality).
Table 1. Overview of the 12 interventions reviewed
InterventionOverviewSources Citeda
aThe findings in this paper are based on information from the sources cited here.
Case ManagersNurse case managers are embedded in primary care practices to help manage care for Medicare Advantage members and collaborate with the clinical team.Hostetter, 2010
Care Management PlusNurse care managers supported by specialized health IT tools are embedded within primary care clinics to orchestrate care for chronically ill elderly patients.Agency for Healthcare Research and Quality, 2011; Dorr, Wilcox, Brunker, et al., 2008.
Community Care of North CarolinaCommunity-based care management provided through networks of primary care physicians (PCPs), a hospital, the Department of Social Services, and the health department. Case managers from a nonprofit work with PCPs in the network to coordinate care and undertake population health management.Domino, Humble, Lawrence, et al., 2009; Lodh, 2005; Ricketts, Greene, Silberman, et al., 2004; Steiner, Denham, Ashkin, et al., 2008; Wilhide and Henderson, 2006.
Geisinger Health System Proven-Health NavigatorGeisinger Health Plan embedded a nurse case manager for every 900 Medicare Advantage patients in primary care practices to identify high-risk patients, design patient-centered care plans, provide care coordination and care transition support, and monitor patients using patient-accessible electronic health records.Gilfillan, Tomcavage, Rosenthal, 2010; Graff, 2009; Paulus, Davis, and Steele, 2008; Steele, Haynes, Davis, et al., 2010.
Geriatric Resources for Assessment and Care of Elders (GRACE)An advanced practice nurse and social worker assess low-income seniors in the home, and develop and implement a care plan with a geriatrics interdisciplinary team, in collaboration with the patient’s PCP.Bielaszka-DuVernay, 2011; Counsell, Callahan, Tu, et al., 2009; Counsell, Callahan, Clark, et al., 2007; Counsell, Callahan, Buttar, et al., 2006.
Group Health Cooperative Medical HomeGroup Health redesigned a clinic to be a PCMH by changing staffing, scheduling, point-of-care, patient outreach, health IT, and management; reducing caseloads; increasing visit times; using team huddles; and introducing rapid process improvements.Group Health News, 2010; Reid, Coleman, Johnson, et al., 2010; Reid, Fishman, Yu, et al., 2009.
Guided CareGuided Care nurses are embedded in the primary care practice to provide assessments, care plans, monthly monitoring, and transitional care to the highest-risk Medicare patients.Boult, Reider, Leff, et al., 2011; Boyd, Reider, Frey et al., 2010; Guided Care Web site, 2010; Leff, Reider, Frick et al., 2009; Marsteller, Hsu, Reider, et al., 2010; Wolff, Rand-Giovanetti, Palmer, et al., 2009; Wolff, Rand-Giovanetti, Boyd, et al., 2010.
Improving Mood-Promoting Access to Collaborative Treatment for Late-Life Depression (IMPACT)A depression clinical specialist care manager (a nurse or psychologist) is embedded in the primary care practice to provide depression care for elderly depressed patients in coordination with the PCP, a consulting PCP, and a psychiatrist.Hunkeler, Katon, Tang, et al., 2006; IMPACT Implementation Center Web site, 2010; Levine, Unützer, Yip, et al., 2005; Unützer, Katon, Williams, et al., 2001; Unützer, Katon, Callahan, et al., 2002; Unützer, Katon, Fan, et al., 2008.
Merit Health System and Blue Cross Blue Shield (BCBS) of North Dakota Chronic Disease Management PilotBCBS embedded a chronic disease management nurse in the clinic for patients with diabetes. The nurse assesses the patients’ knowledge of diabetes, sets goals for disease self-management, establishes the need for in-person or telephone followup, and refers patients to services.Fields, Leshen, and Patel, 2010; McCarthy, Nuzum, Mika, et al., 2008.
Pediatric Alliance for Coordinated CareA pediatric nurse practitioner from each practice allocates 8 hours per week to coordinate the care of children with special health care needs and make expedited referrals to specialists and hospitals; a local parent of a child with special health care needs provides consultations to the practice.Palfrey, Sofis, Davidson, et al., 2004; Silvia, Sofis, and Palfrey, 2000.
Pennsylvania Chronic Care InitiativeIntegrates the chronic care model and the medical home model for patients with diabetes and pediatric patients with asthma and includes the following key components: patient-centered care, teaching self-management of chronic conditions, forming partnerships with community organizations, financial incentives for providers, and making data-driven decisions.AcademyHealth State Health Research and Policy Interest Group, 2009; Chronic Care Management, Reimbursement and Cost Reduction Commission, 2008; Houy, 2008; Torregrossa, 2010.
Veterans Affairs Team-Managed Home-Based Primary CareComprehensive and longitudinal primary care provided by an interdisciplinary team that includes a home-based primary care (HBPC) nurse in the homes of veterans with complex, chronic, terminal, or disabling diseases.Department of Veterans Affairs, 2007; Hughes, Weaver, Giobbie-Hurder, et al., 2000.