There are currently more than 90 commercial health plans, 42 states, and three federal initiatives testing the patient-centered medical home (PCMH) model. Yet, while elements of the medical home have been shown to be associated with better quality and lower cost, there are only a few high-quality, published evaluations of the impact of the PCMH model as a whole. There is an urgent need for rigorous data to strengthen the evidence base of the medical home as well as to improve implementation. In an effort to harness and share lessons from the many disparate medical home pilots and evaluations under way, The Commonwealth Fund established the Patient-Centered Medical Home Evaluators' Collaborative in 2009.

The objectives of the Evaluators' Collaborative are to:

  • reach consensus on a standard core set of outcome measures and instruments;
  • share the consensus on instruments, metrics, and/or methodological lessons with interested researchers around the country; and
  • foster an ongoing and supportive exchange where evaluators share ideas that improve their evaluation designs, analytic approach, and interpretation of findings.

The more than 70 researchers participating in the Evaluators' Collaborative are organized into five workgroups focused on a key dimension of PCMH evaluation: cost/utilization, clinical quality, patient experience, clinician/staff experience, and process/implementation.

The Evaluators' Collaborative has just released its recommended core set of standardized measures to evaluate cost, utilization, and clinical quality outcomes in PCMH evaluation studies (available in Tables 1 and 2 below). We hope these recommendations will help strengthen the quality of medical home research—as well as primary care policy.

Please see the Data Brief for more detail about the selection process and the measures or watch a recording of May 16 webinar about the recommendations.

 Table 1. Core Cost/Utilization Measures for Cross-Study Comparison in PCMH Evaluations


 Emergency department visits, ambulatory care–sensitive (ACS) and all

 Acute inpatient admissions, ACS and all

 Readmissions within 30 days


 Total per member per month costs

 Total per member per month costs for high-risk patients

 Technical issues: all utilization and cost issues should be risk-adjusted; method of pricing should be transparent and standardized if possible

Source: The Commonwealth Fund PCMH Evaluators’ Collaborative.

Table 2. Core Principles and Measures for Assessing Clinical Quality in PCMH Evaluations 

 Quality Measurement Principles
  1. Evaluators should use standardized, validated, nationally endorsed measures. The PCMH Evaluators’ Collaborative clinical quality work group recommends selecting a group of quality measures from Table 3  in the Summary Statement. For purposes of meta-analysis, we recommend the measures listed in Table 4 in the Summary Statement as a core set.
  2. Evaluators should select measures from each of the following areas of primary care: preventive care, chronic disease management, acute care, overuse, and safety.
  3. Evaluators should apply a validated approach to data collection. This is particularly important if pulling measures from the medical record or EHR.
  4. Evaluators should use consistent measures across practices within a demonstration.

Source: The Commonwealth Fund PCMH Evaluators' Collaborative.