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The Safety Net Medical Home Initiative

Patient-Centered Care for the Safety-Net System

Contact: Kathryn Phillips, [email protected]    

The Safety Net Medical Home Initiative, sponsored by The Commonwealth Fund in collaboration with eight co-funders, was a five-year (2008 to 2013) demonstration project designed to help 65 community health centers in five states transform into patient-centered medical homes (PCMHs). In PCMH practices, patients receive well-coordinated services and enhanced access to a care team. Providers practicing in PCMHs use decision support tools, measure their performance, engage patients in their own care, and conduct quality improvement activities to address patients' needs.

As part of the demonstration, five regional coordinating centers were selected to partner with 10 to 15 primary care safety-net clinics in their region. These collaboratives received technical assistance, training, and ongoing support on practice re-design topics such as patient and family engagement and care coordination. The regional centers also received funding to support a medical home facilitator to lead clinic-based quality improvement projects and other activities.

Qualis Health, a Seattle-based quality improvement organization, led the Initiative in partnership with the MacColl Center for Health Care Innovation at Group Health Research Institute to provide support for health centers’ efforts to become medical homes. The Qualis/MacColl team developed a framework, The Change Concepts for Practice Transformation, to help guide primary care practices through the PCMH transformation process. The framework includes eight “change concepts,” or ideas used to stimulate actionable steps, which are divided into four stages:

I . Laying the Foundation: Engaged Leadership and Quality Improvement Strategy

II. Building Relationships: Empanelment and Continuous and Team-Based Healing Relationships

III. Changing Care Delivery: Organized, Evidence-Based Care and Patient-Centered Interactions

IV. Reducing Barriers to Care: Enhanced Access and Care Coordination

The Qualis/MacColl team developed a series of resources and tools to help practices understand the framework and implement each of the change concepts. These resources—all of which are in the public domain—were developed in collaboration with practices that participated in the SNMHI and were informed by reviewers and contributors from across the country. They include:

  • Executive summaries that provide a concise description of the change concept, its role in PCMH transformation, and key implementation activities and actions. 
  • Implementation guides that include a detailed introduction, list relevant key changes, and provide strategies and case studies to guide implementation. 
  • Tools that can be used to test or apply the key changes, such as an interactive “Do-it-Yourself” run chart tool and an secret shopper exercise to test the ease of scheduling an appointment from the patient’s perspective. 
  • Webinars featuring tips and the best practices of SNMHI sites and other leading practices. 
  • The Patient-Centered Medical Home Assessment (PCMH-A), an interactive, self-scoring instrument that can be downloaded, completed, saved and shared. The PCMH-A provides a detailed indication of the extent to which a practice functions as a PCMH, and if completed at regular intervals, can help practices track their progress toward practice transformation. The PCMH-A was updated in 2014 to include an additional question about behavioral health integration under the "Organized, Evidence-Based Care" change concept.

While an evaluation of the Initiative is being led by Marshall Chin and colleagues at the University of Chicago, it’s clear that the 65 health centers made significant achievements. At the final administration of the PCMH-A, all sites demonstrated some level of implementation of all of the key design features of a PCMH and nearly half demonstrated full implementation. In addition, over 80 percent of sites achieved PCMH recognition either from NCQA or their state. The majority of regional coordinating centers were able to build effective practice facilitation programs and have committed to maintaining and growing these programs in the future, spreading what they learned in the SNMHI to other safety-net sites in their local communities. The ultimate goal is for all community health centers in all 50 states to adopt the medical home model.

The implementation guides, all of which are publicly available, are listed below. You can also download a registry of tools and resources.

  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
    d. Organized, Evidence-Based Care: Behavioral Health Executive Summary
    e. Organized, Evidence-Based Care: Behavioral Health Integration Guide
  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 


Other resources include: The Medical Home Digest, a newsletter devoted to providing information about medical home transformation in the safety net, and several tools tied to achieving medical home recognition and implementing medical home payment models. Also see: E. H. Wagner, K. Coleman,R. J. Reid, K. Phillips, M. K. Abrams, J. R. Sugarman, The Changes Involved in Patient-Centered Medical Home Transformation, Clinics in Office Practice, Volume 39, Issue 2 , 241-259, June 2012.

The Commonwealth Fund is joined in support of the project by eight co-funders, including the Colorado Health Foundation
( ), Jewish Healthcare Foundation (Pittsburgh) ( ), Northwest Health Foundation (Portland, Oregon)
( ), Partners HealthCare (Boston) ( ), The Boston Foundation ( ), Blue Cross Blue Shield of Massachusetts Foundation (, Blue Cross of Idaho Foundation for Health ( ), and Beth Israel Deaconess Medical Center (Boston) ( ).


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