Key Changes to Transform into a PCMH

To effectively transform into PCMHs, practices need to embrace eight change concepts, which have been identified through extensive literature review and study of transformation efforts that are in progress.1 Practices can take action by making several key changes within each of these concept areas. The concepts and key changes align with elements of the Chronic Care Model as shown in the following table.

The Patient-Centered Primary Care Collaborative (PDF, 243 KB) medical home framework further defines each of the PCMH change concepts, provides strategies for applying the concepts, and offers examples of how these collective changes have potential to improve patient care, care coordination, and cost savings.

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 quality improvement (QI) Health care organization
Quality improvement strategy Use formal QI model
Establish metrics to evaluate improvement
Optimize use of health information technology
Health care system organization
Information systems
Empanelment 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 Increase availability of and access to services and communication
Care coordination Link patients with community resources
Provide care management services
Community resources
Practice redesign (care management)

The Safety Net Medical Home Initiative created a library of publicly available resources and tools to help practices transform into PCMHs. The resources and tools are categorized according to the eight PCMH change concepts. The library includes a “Getting Started” section that includes a PCMH Assessment (PDF, 1 MB) and key activities checklist.

Diabetes-Specific PCMH Resources: