U.S. Department of Health and Human Services

National Diabetes Education Program

You are here: Transforming Health Care Practices> Enhance Patient-Centered Interactions> Develop a Patient-Centered Medical Home (PCMH)

Develop a Patient-Centered Medical Home (PCMH)

The Patient Centered Medical Home (PCMH) is becoming a centerpiece of national efforts to reform US healthcare and to improve the value of primary care. It addresses gaps in quality care and high healthcare costs. [1][2] It also has been shown that when adults have a medical home and health insurance, racial and ethnic disparities in access and quality are reduced or eliminated. [3]

The Patient-Centered Primary Care Collaborative describes the PCMH home as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It calls for team care that promotes accessibility, compassion, transparency, and is built on trust and communication. Its success is enhanced by health information technology and by smarter ways to pay for care.

Applying the PCMH model provides “accessible, continuous, comprehensive, and coordinated care that is delivered in the context of family and community,” and furthers patient-centered care. [4] PCMH is also referred to as primary care medical home, advanced primary care, and the health care home, The PCMH incorporates dimensions of patient-centered care presented by the Institute of Medicine and the Chronic Care Model. [5] Collaborative management (i.e., patient-centered team care) supports self-care while effective medical, preventive, and health maintenance interventions take place.

Definition and measurement of the PCMH is evolving based on what is being learned in many ongoing evaluations of demonstration projects and medical practices. [2] Many practices are seeking to be recognized by the National Committee for Quality Assurance, URAC (an organization that accredits many types of health care organizations), and the Joint Commission. In addition to the fundamental tenets of primary care (access, comprehensiveness, integration, and relationship), the PCMH involves new ways of organizing and payment reforms. [1][2]

ACP’s Medical Home Builder is an online tool designed to help practices improve patient care, organization, and workflow and become a PCMH.

AAFP’s TransforMed helps primary care practices become high-performing PCMHs.

Key Changes to Transform into a PCMH

An extensive literature review and study of transformation efforts underway identified eight change concepts that practices need to embrace to effectively transform into a PCMH. [5] Within each of these concept areas the authors suggest several key changes or actions practices could make. The concepts and key changes were aligned with elements of the Chronic Care Model.

Inclusion of Chronic Care Model Elements into PCMH Change Concepts

Change Concept

Key Changes

Chronic Care Model Elements

Engaged leadership

Visible leadership for culture change and QI

Health care organization

Quality improvement strategy

Use formal QI model

Establish metrics to evaluate improvement

Optimize use of health information technology

Health care organization

Information systems


Use panel data to manage population

Information systems

Proactive care

Continuous, team-based relationships

Establish and support care delivery teams

Distribute roles and tasks among team

Practice redesign (team care)

Organized evidence-based care

Use planned care according to patient need

Use patient data to enable planned interactions

Use point-of-care reminders

Practice redesign (planned care)

Decision support

Information systems

Patient-centered interaction

Encourage patient involvement in health and care

Provide self-management support at every encounter

Activate patients

Self-management support

Enhanced access

Care coordination

Link patients with community resources

Provide care management services

Community resources

Practice redesign (care management)

Table source: Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR: The changes involved in patient-centered medical home transformation. Prim Care 2012; 39(2): 241-59.

Find additional resources from the Safety Net Medical Home Initiative.

New Payment Approaches

New payment approaches for care provided by a PCMH are being assessed such as a management fee to physician networks that use guidelines, track patients, and report on performance. For example, in Pennsylvania a state wide multi-payer initiative involves monthly member care management fees and shared savings resulting from enhanced access to care (such as reduced emergency room visits and hospitalizations), coordinated care, and improved quality of care. [5]

Find healthcare resources about medical home payment models presented by the Safety Net Medical Home Initiative.

AAFP’s TransforMed helps primary care practices become high-performing PCMHs.


1. Strange KC, Nutting PA, Miller WL, et al.: Defining and measuring the patient-centered medical home. J Gen Intern Med 2010; 25(6): 601-612.

2. Bojadzievski T, Gabbay RA: Patient-centered medical home and diabetes. Diabetes Care 2011; 34(4): 1047-53.

3. Beal AC, Doty MM, Hernandez SE, Shea KK, K. Davis: Closing the Divide: How Medical Homes Promote Equity in Health Care—Results from the Commonwealth Fund 2006 Health Care Quality Survey. New York, NY: The Commonwealth Fund, 2007.

4. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association: Joint Principles of the Patient-Centered Medical Home. Patient Centered Primary Care Collaborative. 2007.

5. Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR: The changes involved in patient-centered medical home transformation. Prim Care 2012; 39(2): 241-59.

6. Gabbay RA, Bailit MH, Mauger DT, Wagner EH, Siminerio L: Multipayer patient-centered medical home implementation guided by the chronic care model. Jt Comm J Qual Patient Saf 2011; 37(6): 265-73.