PCMH Foundations

Using Health Information Technology to Support Quality Improvement in Primary Care
(PDF Version — 796KB)
This white paper describes factors that support the use of health information technology (IT) for quality improvement (QI) in primary care, discusses exemplary cases, and makes recommendations to support and increase the use of health IT to improve the quality of health care delivery and population health outcomes.

Strategies to Ensure HITECH Supports the Patient Centered Medical Home HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of the medical home model.
(PDF Version — 321KB)
HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of the medical home model. This brief discusses the ways in which HITECH and broader health reform legislation could ensure EHRs are implemented in a way that supports primary care transformation.

Necessary But Not Sufficient: The HITECH Act and Health Information Technology’s Potential to Build Medical Homes
(PDF Version — 175KB)
HITECH programs and other current Federal legislation are necessary but not sufficient for driving widespread adoption of the medical home model. This brief discusses the ways in which HITECH and broader health reform legislation could ensure EHRs are implemented in a way that supports primary care transformation.

Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care
(PDF Version — 752KB)
Practice-Based Population Health is an approach to care that uses information on a group of patients within a primary care practice(s) to improve the care and clinical outcomes of patients within that practice. This report describes this approach and discusses the information management functionalities that may help primary care practices to move forward with this type of proactive management.

AHRQ Health IT
AHRQ's Health IT Portfolio develops and disseminates evidence to inform policy and practice on how health information technology can improve the quality of health care.

HealthIt.gov
The Office of the National Coordinator for Health Information Technology (ONC) is the principal federal entity charged with coordination of nationwide efforts to implement and use the most advanced health information technology and the electronic exchange of health information.

Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home
(PDF Version — 181KB)
The majority of PCMH demonstrations have not explicitly addressed the integration of mental health services into primary care. This paper examines successful approaches to delivering mental health treatment in primary care and PCMH settings.

Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms
(PDF Version — 663KB)
"Neighbors" in the medical neighborhood include the medical home, specialists, hospitals, health plans, and other stakeholders. This paper describes how these neighbors could work together better, thus allowing the medical home to reach its full potential to improve patient outcomes.

Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers
(PDF Version — 84KB)
Efforts to redesign primary care require multiple supports. Two potential members of the primary care team—practice facilitator and care manager—can play important but distinct roles in redesigning and improving care delivery.

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.

Ensuring that Patient Centered Medial Homes Effectively Serve Patients with Complex Needs
(PDF Version — 88KB)
The PCMH model currently offers or coordinates many of the services required for patients with complex needs. This decisionmaker brief offers programmatic and policy changes that can help practices, especially smaller ones, better deliver services to all patients, including those with the most complex health needs.

Integrating Mental Health and Substance Use Treatment in the Patient-Centered Medical Home
(PDF Version — 181KB)
The majority of PCMH demonstrations have not explicitly addressed the integration of mental health services into primary care. This paper examines successful approaches to delivering mental health treatment in primary care and PCMH settings.

Coordinating Care for Adults with Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solutions
(PDF Version — 91KB)
Patients who have complex health needs typically require both medical and social services and support from a wide variety of providers and caregivers. This paper discusses strategies that are needed to help primary care practices perform as effective medical homes to coordinate such services for patients with complex care needs.