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 2. Target populations and implementation settings
 Target PopulationImplementation Setting
Intervention NameTarget Population (and Consent Rate When Reported)Includes All PatientsLimited to Medicare PatientsLimited to Patients With Chronic Physical or Mental IllnessIncludes Patients With Both Fee-for- Service and Managed Insurance CoveragePractice SettingLimited to Larger Delivery SystemsNumber of PracticesUse Electronic Health Records
aNote: "Practices" also includes clinics and health centers.
Aetna’s Embedded Case ManagersMedicare beneficiaries enrolled in Medicare Advantage Yes  Practices across the United States 36 
Care Management PlusMedicare fee-for-service patients aged 65 or older with complex chronic care needs identified by the primary care physician YesYes Moderate-sized primary care clinics (4 family medicine and 3 internal medicine practices) in a large Integrated Delivery System (IDS) in UtahYes7Yes
Community Care of North CarolinaMedicaid patients in North Carolina  YesYes12 PCMH networks in North Carolina (exact number of primary care practices in networks not reported) Many 
Geisinger Health System ProvenHealth NavigatorEnrollees in Geisinger Health Plan’s Medicare Advantage (MA) plan Yes  GHS practices in rural central Pennsylvania in a large IDSYes11Yes
Geriatric Resources for Assessment and Care of EldersMedicare patients with incomes less than 200% of the Federal poverty level; 43% consent rateYes  YesPrimary care physicians in community-based health centers in urban area of Indiana in an IDSYes6Yes
Group Health Cooperative Medical HomeAll adult patients in the Seattle clinicYes  YesModerate-size primary care clinic in Seattle operating within an IDS.Yes1Yes
Guided CareRoughly 25% of a practice’s sickest aged Medicare patients; 38% consent rate YesYesYesPrimary care teams ("pods" of 2 to 5 physicians), including 18 physicians from practices in 3 large delivery systems in Baltimore/Washington metropolitan areasYes8Yes
Improving Mood-Promoting Access to Collaborative Treatment for Late-Life DepressionSocioeconomically diverse sample of elderly (=60 years) patients with major depression and/or dysthymia  YesYes450 primary care providers in primary care clinics operating in IDSs (mostly academic medical centers) within 8 health care organizations in 5 StatesYes18 
Merit Health System and Blue Cross Blue Shield (BCBS) of North Dakota Chronic Disease Management PilotPatients with diabetes  YesYesA MeritCare internal medicine clinic in an IDS in North DakotaYes1Yes
PA Chronic Care InitiativeAdult patients with diabetes and pediatric patients with asthma  YesYesPractices in southeastern Pennsylvania 32 
Pediatric Alliance for Coordinating Care (PACC)Children with special health care needs  YesYesPediatric primary care practices in the Boston area (4 private practices; 2 community health centers) 6 
Veterans Affairs Team-Managed Home-Based Primary CareVeterans with limitations in 2 or more activities of daily living (ADLs) or a prognosis of terminal illness or homebound with congestive heart failure or chronic obstructive pulmonary disease; 89% consent rate  YesYesVA medical centers with HBPC programsYes16