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 17. Descriptions of the interventions, by AHRQ PCMH principles and facilitators
AHRQ PCMH Principles and Facilitators
InterventionOverviewPatient-CenteredComprehensive CareCoordinated CareAccess to CareSystems Approach to Quality and SafetyPayment and Other Resources to the Primary Care PracticeHealth IT
Aetna’s Embedded Case Managers Program assigns nurse case managers to primary care practices to help manage care for Medicare Advantage members and collaborate with the clinical team Care plans; disease management coaching; family members can sit in on patient office visits Team-based care, including the nurse case manager and clinical team, who address needs of patients with multiple chronic conditions, including dementia and depression, and provide end-of-life care Case manager coordinates care, including hospital discharge plan, and links patients to social services No changes in access to care Case manager uses clinical decision support software to identify gaps in treatment; reviews data weekly with the clinical team and monthly with the medical director Program provides nurse case managers; practice receives an extra fee for patients enrolled in program and incentives for meeting quality targets Clinical decision support software
Care Management Plus Nurse care managers, supported by specialized health IT tools within primary care clinics, orchestrate care for chronically ill elderly patients Develop care plan with patients and family; teach self-management to patients Team-based approach to patient assessment and care planning Care manager coordinates care across providers Patient-specific secure messaging system facilitates communication Care management tracking (CMT) database embeds disease protocols and generates flexible, patient-specific care plans, as well as aggregate statistics No payment component. Program provides care manager and specialized IT tools Existing electronic health records (EHRs) and CMT to track all contacts with patients, families and providers; generate reminders, calculate patient statistics; and provide electronic protocols
Community Care of North Carolina Community-based care management provided through networks of primary care providers (PCPs), a hospital, the Department of Social Services, and the health department. Case managers from a nonprofit work with PCPs to coordinate care and undertake population health management Providers and/or case managers (a nurse, social worker, or other clinician) coach and educate patients on disease management and assess psychosocial needs Practice team includes primary care provider and case managers who provide comprehensive case management Case manager coordinates with providers, hospitals, health departments, and social service agencies that are part of network; web-based program used to coordinate care 24/7 on-call assistance; case managers make home visits Random chart reviews to assess adherence to case management protocols; review of claims data and charts to assess clinical improvements PCPs receive $2.50 per member per month (PMPM) for medical home and population management activities and the help of the case manager; networks receive $3 PMPM ($5 PMPM for elderly or disabled patients) No standardized health IT component; some participating physicians may be using EHRs
Geisinger Health System ProvenHealth Navigator Geisinger Health Plan (GHP) provided one nurse case manager for every 900 Medicare Advantage patients in each primary care practice to identify high-risk patients, design patient-centered care plans, provide care coordination and care transition support, and monitor patients using patient-accessible EHRs Case manager develops individualized care plans; provides self-management education to patient and family; assesses patient satisfaction. Care teams composed of PCP, physician’s assistant, nurse practitioners, nurses, administrative staff, and case manager address patient’s care needs, including medication management and end-of-life planning Case manager coordinates care across providers, including during care transitions, and conducts outreach to home health agencies and nursing homes 24/7 access, same-day appointments, self-scheduling using EHR, direct telephone lines to case managers, home interactive voice response for high-risk or postdischarge patients EHRs provide preventive and chronic care reminders and embedded care workflows; program tracks 10 quality-of-care metrics, including chronic and preventive care, postdischarge followup, and patient satisfaction and experience; monthly meetings with primary care practices, navigators, and GHP staff to review results Program provided case manager and funding for new services, physician and practice transformation stipends, and staff incentives, including employee stipends and quarterly performance-based payments; program also used a shared savings incentive model based on quality and efficiency performance Existing EHR embeds care workflows, captures patient information, tracks patient care, generates reminders, and calculates patient statistics; EHR is patient-accessible via a Web-based interface; Bluetooth scales for daily monitoring of heart failure patients
Geriatric Resources for Assessment and Care of Elders Advanced practice nurse and social worker (GRACE support team) assess low-income seniors in home, and develop and implement a care plan with a geriatrics interdisciplinary team, in collaboration with the patient’s primary care provider Initial and annual in-home comprehensive geriatric assessment; annual individualized care plan; minimum 1 in-home visit to review care plan and 1 face-to-face or telephone contact per month with patients and family members or caregivers Care plan developed and implemented in collaboration with the GRACE interdisciplinary team of a pharmacist, physical therapist, community resource expert, and mental health case manager, led by a geriatrician and the patient’s PCP. The care plan covers physical, mental, and social needs The nurse practitioner-social worker team coordinates with the inpatient and nursing home teams for patients who have been hospitalized or using skilled nursing facility services; the team conducts a home visit and full review of the case after hospital and ED visits. They also coordinate specialty visits Dedicated telephone line to GRACE support team Care protocols for evaluation and management of 12 common geriatric conditions No payment component. Program provides assistance of GRACE support team to primary care practice. Integrated EHRs and web-based tracking tool support care management and coordination of care.
Group Health Cooperative Medical Home Group Health redesigned one pilot 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 rapid process improvements Individualized care plans viewable through patient EHRs Care team composed of PCP, nurse care manager, pharmacist, medical assistant, and a Licensed Practical Nurse deliver primary care to patients, which includes pre-visit contact to discuss concerns Nurse works with PCP to coordinate care across providers, including during transitions between care sites 24-hour telephone access to consulting nurse, same-day appointments, online services, self-scheduling using EHRs’ direct telephone lines to case managers EHR provides preventive and chronic care reminders and embeds care workflows Physicians paid a salary and shared savings based on quality targets achieved; program provided additional staff Existing EHR records patient information and care, generates reminders; its messaging feature is used for real-time specialist consultations. Patients can access EHRs
Guided Care GC nurse (GCN) joins primary care practice, provides assessments, care plans, monthly monitoring, and transitional care to highest-risk Medicare patients Home-based assessment; individualized care plan and a patient self-care plan to promote self-management; group classes for caregivers GCN and PCP discuss and modify individualized care guide. GCN proactively manages patients, mostly by telephone GCN coordinates care and provides care plan to other providers; facilitates care transitions; monitors patients during hospital stays; and facilitates access to community services Telephone access to GCN Evidence-based guidelines, embedded in Guided Care EHRs, used to generate individualized care guides and monthly reports on GCN performance. GCN, study team, and nurse managers met monthly to review performance No payment component. Program provides on-site registered nurse (the GCN) EHR embeds evidence-based guidelines; generates individualized care guides based on guidelines and patient information; tracks patients; and sends reminders to GCN
Improving Mood-Promoting Access to Collaborative Treatment for Late-Life Depression Depression care for elderly depressed patients is integrated into primary care via a depression clinical specialist (DCS) (a nurse or psychologist) who coordinates care between the PCP, consulting PCP, and psychiatrist Patient and DCS establish individualized care plan, which includes education, care management, problem-solving treatment, support for antidepressant use, and relapse prevention DCS, in consultation with the consulting PCP and team psychiatrist, works with patient and regular PCP to provide depression care. DCS supports antidepressant therapy and behavioral activation DCS does not coordinate with external providers (psychiatrist and DCS become part of internal team) Telephone and in-person contact with DCS Evidence-based treatment algorithm used by DCS and care team. The DCS and psychiatrist review progress weekly over the year-long intervention No payment component. Program provides DCS, consulting PCP, and psychiatrist Internet-based system used to record patient contacts; electronic reminders to DCS if time for a contact or on ineffective treatment
IMerit Health System and Blue Cross Blue Shield of North Dakota Chronic Disease Management Pilot BCBS embedded a chronic disease management nurse in a clinic for patients with diabetes. The nurse assesses patient knowledge of diabetes, sets goals for disease self-management, establishes the need for in-person or telephone followup, and refers to services Nurse and patients set goals, and nurse provides self-management education Focused on diabetes care Nurses make referrals for services such as nutrition counseling Nurse available by telephone (unclear whether 24/7 access is available) EHRs allow patients and physicians to track patient outcomes and provide aggregate performance information to physicians $20,000 startup grant and 50% of savings generated in the first year of the pilot. Program provides a disease management nurse in the clinic. After the pilot, BCBS replaced the startup grant and in-kind nurse with a disease management fee Existing EHR used by physicians and patients to track patient care
IPediatric Alliance for Coordinated Care A pediatric nurse practitioner (PNP) from each practice allocates 8 hours per week to coordinate 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 consults to the practice Individualized health plan developed with the patient and family Practice-based team care that includes physicians, PNP, office staff, and family consultants. Provides 8 hours per week of comprehensive case management; social support and activities PNP makes expedited referrals and coordinates care across providers (e.g., therapists, school nurses), and education, social services, and recreation After-hours coverage; PNP conducts home visits PNPs and physicians receive ongoing training. Local parent provides feedback to practice No payment to practices. Stipend to family members serving as consultants. Continuing medical education for physicians No health IT component
Pennsylvania Chronic Care Initiative Integrates the chronic care model and the medical home model for patients with diabetes and pediatric patients with asthma and includes patient-centered care, teaching self-management of chronic conditions, forming partnerships with community organizations, financial incentives for providers, and making data driven-decisions Self-management support and coaching Practice-based team care, which includes case managers, physicians, nurses, and office staff Referral process to community services Timely or same-day appointments Use of performance measures and evidence-based guidelines to inform planning and treatment Providers in practices that meet National Committee for Quality Assurance (NCQA) PCMH standards are eligible for supplemental payment, including an annual payment for clinicians ($40,000 to $95,000), infrastructure payments (starting at $20,895), and provider performance incentives Electronic patient registry
Veterans Affairs Team-Managed Home-Based Primary Care Comprehensive 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, and disabling diseases Individualized treatment plan developed in collaboration with patient and caregiver; HBPC nurse teaches both patients and caregivers about the disease, treatment, and self-care; caregiver support provided Patient assessment by HBPC team members from at least three different disciplines (social workers, dietitians, therapists, pharmacists, and paraprofessional aides); weekly team meetings HBPC team coordinates patient care across all settings, and is involved in hospital discharge planning 24-hour contact for patients Mandatory annual performance improvement plan; quarterly medical record reviews No payment component. Physicians are salaried staff who devote a specific percentage of time to the HBPC program HBPC information system designed to help HBPC teams manage their patients and resources, as well as to provide VA Central Office with site-specific information for all programs