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Becoming a Medical Home: Implementation Guides



The patient-centered medical home is a model of primary care that can improve health care quality as well as clinicians', staff members', and patients' experiences. The model can also increase efficiency. As part of the Commonwealth Fund--supported Safety Net Medical Home Initiative, Qualis Health and the MacColl Center for Health Care Innovation have identified eight key strategies that primary care sites can implement to become patient-centered medical homes. A set of implementation guides are available to help primary care providers put these strategies into practice in order to expand access to care, coordinate care, and better engage patients. 

The Issue

Recent studies show that most primary care practices do not meet the functional requirements of a patient-centered medical home. While the Patient Centered Primary Care Collaborative’s Joint Principles for a Patient-Centered Medical Home outline the core components of the medical home model, providers need assistance on how to put these principles into practice. Based on the experiences of 65 safety net primary care sites that are working to become medical homes, Qualis Health and the MacColl Institute for Healthcare Innovation have developed concrete definitions of the changes needed as well as implementation guides to assist practices in becoming patient-centered medical homes.

Target Audience

Primary care practices

The Intervention

The Qualis/MacColl team identified eight key strategies, or "change concepts," that serve as the framework for patient-centered medical home implementation. They also developed 16 implementation guides to help primary care providers put those concepts into practice:

  1.  Engaged Leadership
    a. Engaged Leadership Executive Summary
    b. Engaged Leadership: Strategies for Guiding PCMH Transformation
    c. Engaged Leadership: How Health Center Board Members Can Support PCMH Transformation
  2. Quality Improvement Strategy
    a. Quality Improvement Strategy Executive Summary
    b. Quality Improvement Strategy Part 1: Tools to Make and Measure Improvement
    c. Quality Improvement Strategy Part 2: Optimizing Health Information Technology for Patient-Centered Medical Homes  
  3. Empanelment 
    a. Empanelment Executive Summary
    b. Empanelment: Establishing Patient-Provider Relationships
  4. Continuous and Team-Based Healing Relationships 
    a. Continuous and Team-Based Healing Relationships Executive Summary
    b. Continuous and Team-Based Healing Relationships: Improving Patient Care Through Teams
    c. Continuous and Team-Based Healing Relationships Supplement: Elevating the Role of the Medical/Clinical Assistant
  5. Organized, Evidence-Based Care
    a. Organized, Evidence-Based Care Executive Summary
    b. Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations
    c. Organized, Evidence-Based Care: Improving Care for Complex Patients: The Role of the RN Care Manager
  6. Patient-Centered Interactions 
    a. Patient-Centered Interactions Executive Summary
    b. Patient-Centered Interactions: Engaging Patients in Health and Healthcare 
  7. Enhanced Access 
    a. Enhanced Access Executive Summary
    b. Enhanced Access: Providing the Care Patients Need, When They Need It
  8. Care Coordination 
    a. Care Coordination Executive Summary
    b. Care Coordination: Reducing Care Fragmentation in Primary Care 

Each guide defines the strategy and provides step-by-step instructions on how to implement it. The guides also offer additional resources, including one or more case studies demonstrating how a primary care practice has successfully implemented the key change.

For More Information

Visit the Safety Net Medical Home Initiative Web site at

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