U.S. Department of Health and Human Services

PCMH Definition & Measurement

Tools You Can Use

Patient-Centered Primary Care Collaborative: Mapping the Medical Home Movement includes a diverse range of programs using patient centered medical homes (PCMH) and enhanced primary care teams as the model for improving health care delivery.

The Patient-Centered Primary Care Collaborative describes the Patient Centered Medical Home (PCMH) 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 is built on trust and communication and promotes accessibility, compassion, and transparency. 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.1

Tools You Can Use

NCQA/Merck: Transitioning Your Practice to the Patient-Centered Medical Home is a video presenting key characteristics of PCMHs, why your office may want to become a PCMH, and how to do so.

The PCMH incorporates dimensions of patient-centered care presented by the Institute of Medicine and the Chronic Care Model.2 Collaborative management (i.e., patient-centered team care) supports self-care while effective medical, preventive, and health maintenance interventions take place.

The definition and measurement of the PCMH is evolving based on what is being learned in many ongoing evaluations of demonstration projects and medical practices.3 Many practices are seeking to be recognized by the National Committee for Quality Assurance (NCQA), URAC (an organization that accredits many types of health care organizations), and The Joint Commission. In addition to the fundamental tenets of primary care(including access, comprehensiveness, integration, and relationship), the PCMH involves new ways of organizing and payment reforms.3,4

Let the Evidence Guide You

Concerned that small practices or those with limited resources will be challenged to transform into PCMHs?

Wang JJ, Winther CH, Cha J, et al. Patient centered medical home and quality measurement in small practices. Am J Manag Care. 2014;20(6):481-9.

The American College of Physicians’ Practice Advisor is an online tool designed to help practices improve patient care, organization, and workflow and become a PCMH.


1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. Washington, DC: Patient Centered Primary Care Collaborative; 2007.
2. 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.
3. Stange KC, Nutting PA, Miller WL, et al. Defining and measuring the patient-centered medical home. J Gen Intern Med. 2010;25(6):601-12.
4. Bojadzievski T, Gabbay RA. Patient-centered medical home and diabetes. Diabetes Care. 2011;34(4):1047-53.

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