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Assessing Progress Toward Becoming a Patient-Centered Medical Home: An Assessment Tool for Practice Transformation

The Issue

Patient-centered medical homes (PCMHs) are gaining traction, and getting attention from policymakers, purchasers, and providers, particularly with passage of the Affordable Care Act. The Safety Net Medical Home Initiative, sponsored by The Commonwealth Fund, helped 65 safety-net clinics become PCMHs. To help monitor progress and identify additional opportunities for improvement, researchers developed the Patient-Centered Medical Home Assessment. This study sought to test the tool’s validity in measuring progress in the PCMH transformation process.

What the Study Found

The assessment asks teams at each medical home site to rate their care delivery on 33 measures associated with eight “change concepts,” like engaged leadership and care coordination. The self-assessment was completed every six months between March 2010 and September 2012. During that period, overall scores increased, with the greatest improvements seen in patient empanelment, continuous and team-based healing relationships, and organized and evidence-based care. To test the validity of the scores, external observers also evaluated the sites; they agreed with the self-assessment scores 82 percent of the time.


Although the assessment tool will be useful to any primary care practice working to become a patient-centered medical home, the authors recommend additional testing in more varied settings.

Publication Details



D. M. Daniel, E. H. Wagner, K. Coleman et al., "Assessing Progress Toward Becoming a Patient-Centered Medical Home: An Assessment Tool for Practice Transformation," Health Services Research, published online Oct. 21, 2013.