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Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes

The patient-centered medical home has been proposed as a model for transforming primary care and improving efficiency and effectiveness in the health care system. This report outlines and describes the changes that most medical practices would need to make to become patient-centered medical homes. The broad "change concepts," as the report terms them, include: engaged leadership; a quality improvement strategy; empanelment or linking patients with specific providers to ensure the continuity of the patient–provider relationship; continuous and team-based healing relationships, including cross-training staff to allow team members to play various roles; organized, evidence-based care, including the use of decision support systems; patient-centered interactions to increase patients' involvement in their own care; enhanced access to ensure patients have access to care and their clinical information after office hours; and care coordination to reduce duplication of services and increased anxiety and financial costs for patients and their families.

A robust primary care sector is the foundation of a more effective and efficient health care system. However, achieving a robust primary care sector will require widespread practice transformation. A growing consensus supports the patient-centered medical home (PCMH) model, proposed as joint principles by the major primary care professional associations, as the blueprint for practice transformation. Under these principles, a PCMH would provide each person with a personal physician who leads a team that takes responsibility for ongoing care for all health issues and coordinates care with other service providers. Medical homes would also ensure the quality and safety of their care through performance measurement and continuous quality improvement and provide their patients with enhanced access. Finally, payment systems would reward the added value provided by medical homes. While these joint principles describe the general expectations of a PCMH, they do not make concrete suggestions for how primary care organizations can change their practices to become one.

As part of The Commonwealth Fund’s Safety Net Medical Home Initiative (SNMHI), this report sought to develop a more detailed and concrete definition that describes the changes that most practices would need to make to become PCMHs. After reviewing the literature, the study team proposed eight characteristics of medical homes—called change concepts—which provide general directions for transforming a practice. We further identified more specific practice modifications called key changes for each change concept. A technical expert panel assembled for the SNMHI reviewed the change concepts and key changes and suggested alterations. A second panel, convened for another PCMH transformation project, also provided feedback.

Many, but not all, of the change concepts and key changes are supported by evidence of positive effects on important outcomes. Therefore, the following eight change concepts should be viewed as general guidance for transforming the practice as well as opportunities for innovation and adaptation.

Engaged Leadership
To become a PCMH, most practice organizations must undergo wrenching cultural and system changes. This requires visible leadership that can help staff envision a better organization and improved care, establish a quality improvement apparatus and culture, and ensure that staff have the time and training to work on system change.

Quality Improvement Strategy
Effective leadership ensures that the organization embraces an effective improvement strategy that relies on routine performance measurement to identify opportunities for improvement and uses rapid-cycle change methods to test ideas for change. Patient-centered organizations routinely obtain and use patient experience data to inform improvement efforts and involve patients as well as staff in efforts to make the practice more responsive to the needs and preferences of their clientele. Quality improvement is easier and more effective if practices put in place information systems that support critical functions such as performance measurement, provider alerts and reminders, computerized order entry, and population management.

Considerable evidence has demonstrated that positive outcomes such as improved health status and higher patient satisfaction result from care provided by the same clinician and care team over time. A deliberate effort by the practice to link each patient or family with a specific provider—a process known as empanelment—facilitates continuity of relationship. In addition, the creation of patient panels allows practice teams to monitor their panel to identify and reach out to patients needing more attention and services.

Continuous and Team-Based Healing Relationships
Robust and lasting clinician–patient relationships are at the heart of every medical home. The involvement of practice staff other than clinicians has been shown to improve care and outcomes. Team care begins with defining the critical roles and tasks involved, assigning them to the most appropriate members of the team, and ensuring they are appropriately trained to perform them well. Cross-training of staff for critical roles gives practices the capacity to better deal with staff absences and turnover.

Organized, Evidence-Based Care
Medical homes must be able to deliver high-quality care. Two critical components of the chronic care model are included in this change concept: planned care and decision support. Using information system tools like registries enables practices to identify gaps in care for patients before they visit, so practice teams can plan and organize care to ensure all patient needs are met. Decision support systems improve care by alerting providers when services are needed and helping them make evidence-based choices.

Patient-Centered Interactions
Patient-centered practices endeavor to increase their patients’ involvement in decision-making, care, and self-management. They see effective health care as being respectful of a patient’s needs, preferences, and values, and work to ensure patients understand what is being communicated to them.

Enhanced Access
Providing patients with the ability to contact their care team, or at least someone with access to their clinical information, both during and after office hours is an essential feature of a medical home. Ensuring access also means helping patients attain and understand health insurance.

Care Coordination
Many patients benefit from services outside the medical home, from medical or behavioral specialists, community service agencies, hospitals, and emergency rooms, for example. But these handoffs and transitions, if not managed well, can lead to serious problems in care, duplication of services, and increased anxiety and financial costs for patients and their families. Effective care coordination involves helping patients find and access high-quality service providers, ensuring that appropriate information flows between the PCMH and the outside providers, and tracking and supporting patients through the process.

These eight change concepts and their associated key changes are being tested in 65 practices across the country as part of the Safety Net Medical Home Initiative. This experience will provide insight into what it takes for busy practices to implement these ideas and become medical homes.

Publication Details



E. H. Wagner, K. Coleman, R. J. Reid et al., Guiding Transformation: How Medical Practices Can Become Patient-Centered Medical Homes, The Commonwealth Fund, February 2012.