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Practice Transformation 101

History of the PCMH Model of Care

The “medical home” was pioneered in the 1960s by the American Academy of Pediatrics as an approach for providing well-coordinated, patient-centered care for children with special healthcare needs. In 2007, the major primary care associations endorsed the Joint Principles of the Patient-Centered Medical Home, which articulated the features of a primary care medical home and emphasized its relevance for all patients and practice types.1

This new model of care caught the attention of employers, payers, policymakers and delivery systems by promising to:

  • Improve quality, access and continuity
  • Improve patients’ experience of care
  • Reduce health disparities
  • Improve staff satisfaction and reduce provider burnout
  • Reduce avoidable hospital admissions
  • Reduce total costs of care

Early demonstrations were encouraging, and the “Patient-Centered Medical Home (PCMH) Model of Care” was quickly recognized as primary care’s pathway for achieving the Triple Aim. Local, state and national initiatives provided resources for primary care practices of all types to redesign their clinical and administrative systems to improve the delivery of patient care. Recognition and certification programs were also developed in order to validate a practice’s medical home capacity (e.g., expectations for enhanced access to care).

In the years following the release of the Joint Principles, several organizations developed frameworks to operationalize the Joint Principles and help primary care practices understand the specific changes they would need to make to become medical homes. These frameworks share many commonalities.

Features of a Medical Home2

  • Patient-centered: A partnership between practitioners, patients and their families ensures that decisions respect patients’ wants, needs and preferences, and that patients have the education and support they need to make decisions and participate in their own care.
  • Comprehensive: One team of care providers is wholly accountable for a patient’s physical and mental health care needs, including prevention and wellness, acute care and chronic care.
  • Coordinated: Care is organized across all elements of the broader healthcare system, including specialty care, hospitals, home health care, community services and supports.
  • Accessible: Patients are able to access services with shorter waiting times, “after hours” care, 24/7 electronic or telephone availability and strong communication through health IT innovations.
  • Committed to quality and safety: Clinicians and staff enhance quality improvement to ensure that patients and families make informed decisions about their health.

PCMH Adoption: What Does It Take to Become a Medical Home?

Today, the process of implementing the PCMH Model of Care is often called “practice transformation” because it requires making changes that touch every aspect of practice. These changes profoundly impact the culture of the practice and the orientation of its staff.

Qualis Health’s Pathway to Practice Transformation provides a road map to help practices navigate these changes.

Read more about the Pathway to Practice Transformation and how we can help you.

Evidence of Impact

A growing body of evidence confirms that advanced primary care is associated with improved clinical quality, enhanced patient and staff experience, reduced utilization of emergency departments, and reduced hospital readmissions. Policies or programs to advance patient-centered care using the PCMH or a related model have been adopted in 43 states,3 and there are 500 programs dedicated to improving the health system through enhanced primary care.4

Many of these programs seek to verify changes in practice operations through independent recognition or accreditation bodies. Nearly 7,000 primary care practices—including 35,000 clinicians—in 49 states have attained recognition as a PCMH from the National Committee for Quality Assurance.2 Many others have been recognized as medical homes by The Joint Commission for Ambulatory Care. At least six states have developed their own medical home recognition or certification programs.


1 Joint Principles of the Patient‐Centered Medical Home. 2007. Available at: http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. Accessed July 2014.

2 National Committee for Quality Assurance. The Future of Patient-Centered Medical Homes: Foundation for a Better Health Care System. Public Policy Series, 2014. Available at: http://www.ncqa.org/Portals/0/Public%20Policy/2014%20Comment%20Letters/The_Future_of_PCMH.pdf. Accessed December 1, 2014.

3 National Academy for State Health Policy. Medical home and patient-centered care, interactive map. Available at: http://www.nashp.org/med-home-map. Accessed December 9, 2014.

4 Nielsen M, Gibson L, Buelt L, Grundy P, Grumbach K. The Patient-Centered Medical Home’s Impact on Cost and Quality, Review of Evidence, 2013-2014. Washington, DC: Patient-Centered Primary Care Collaborative; 2015. Available at: https://www.pcpcc.org/resource/patient-centered-medical-homes-impact-cost-and-quality. Accessed April 10, 2015.

5 Patient-Centered Primary Care Collaborative. Features of a medical home. Available at: http://www.pcpcc.org/about/medical-home. Definitions adapted from: Agency for Healthcare Research and Quality, Patient-Centered medical Home Resource Center. Defining the PCMH. Available at: http://www.pcmh.ahrq.gov/page/defining-pcmh. Accessed August 2015.

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»our framework: the Pathway to Practice Transformation