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Monitoring Medical Home Implementation



The Patient-Centered Medical Home Assessment (PCMH-A) is a self-assessment tool that was developed by the MacColl Center for Health Care Innovation and Qualis Health for the Safety Net Medical Home Initiative to help practices understand to what degree they function as a medical home and to identify opportunities for improvement. 

The Problem

Before undertaking the process of becoming a medical home, medical practices must identify ways in which they are already delivering patient-centered primary care as well as areas in which they need to improve.


Health care practices

The Intervention

The PCMH-A is an interactive, self-scoring questionnaire available free of charge on the Safety Net Medical Home Initiative Web site. It has been extensively tested by the 65 safety-net sites participating in the initiative as well as by other organizations. The survey is designed to help primary care practices implement state-of-the-art patient-centered care in a medical home.

The questions cover the eight implementation strategies, or change concepts, that Qualis Health and the MacColl Center have identified as being necessary for practices to transform to a medical home. Members of the care team are asked to rate their processes for delivering care in the following areas:

The lowest possible score on any given item is one, which corresponds to "limited support for patient-centered care in the context of a medical home." A score between 10 and 12 on an item means "fully developed patient-centered care in the context of a medical home." The scoring algorithm helps practices calculate scores within a particular area (e.g., team-based care) as well as an overall score for medical home transformation.

The Safety Net Medical Home Initiative has also developed a series of implementation guides for practices on each of the change concepts.

For More Information

To download the PCMH-A, go to

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