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Medical Home Measurement & Improvement Resources


Many different types of individuals may be interested in the medical home concept, including states, medical practices, and families. Resources to assist each of these audiences understand, measure, and improve upon medical home performance can be found below. General resources for anyone seeking to learn more about the medical home concept can also be found below.


    Learn About the Medical Home

    Family-Centered Care Medical Home Overview: This page on the National Center for Medical Home Implementation Web site provides an overview the medical home model, evidence to support this model, and tools for communicating the model to patients, families, and practices.

    The Patient-Centered Medical Home Resource Center: The Agency for Healthcare Research and Quality (AHRQ) hosts this site to provide an archive of federal PCMH activities.

    History of the Medical Home Concept: Sia C, Tonniges TF, Osterhus E, Taba S. History of the Medical Home Concept. Pediatrics. 2004;113:1473-1478.

    American Academy of Pediatrics (AAP) Policy Statement on Medical Home: American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002, reaffirmed 2008; 110:184-187. PDF: 44.8 KB

    Joint Principles of the Patient-Centered Medical Home: Published in 2007 by the four primary care societies, the Joint Principles of the Patient-Centered Medical Home (PCMH) outlines comprehensive primary care for adults, children and families. PDF: 40KB

    Measuring Medical Home: This manual compiled by the Child and Adolescent Health Measurement Initiative (CAHMI) takes a look at the medical home concept and components. PDF: 768KB; PDF with Appendices: 4.36MB

    Medical Home Resources for States

    National Center for Medical Home Implementation (NCMHI) National and State Initiatives Page: NCMHI and the National Academy for State Health Policy have compiled a collection tools/resources that highlight how public programs are advancing pediatric medical homes.

    State Measurement in National Child Health Surveys: This manual compiled by the CAHMI takes a look at the medical home concept and components in the National Survey of Children's Health and National Survey of Children with Special Health Care Needs. PDF: 768KB

    Quantifying the Medical Home Concept: Excerpt from CAHMI’s the Medical Home Manual: Read about how the Medical Home concept is derived. PDF: 616KB

    Methodology for Medical Home in the 2007 NSCH: Excerpt from CAHMI’s Medical Home Manual: Learn about the methodology for Medical Home, including calculation for each subcomponent. PDF: 460KB

    Influence of Survey Design on Medical Home Prevalence: Excerpt from CAHMI’s Medical Home Manual: Read about how the design of national surveys impacts the prevalence of Medical Home. PDF: 656KB

    Ohio Medical Home Focus Group Report: The medical home measure was tested using focus groups with parents. Learn more about parent understanding and interpretation of the items in this summary report of Medical Home Focus Groups in Ohio.

    National Academy for State and Health Policy( NASHP) and NCHMI’s Advancing the Medical Home Model for Children and Youth State Profiles: The National Academy for State Health Policy (NASHP) is collaborating with the National Center for Medical Home Implementation (NCMHI) on the development of state profiles designed to highlight how public health programs are implementing and advancing the medical home model in pediatric populations. These updates are part of a formal partnership between NASHP and the NCMHI that will focus on exchanging information to improve medical home access for children and youth in medically underserved populations.

    NASHP State Implementation of Medical Home & Patient-Centered Care Database: The National Academy for State and Health Policy (NASHP) has a database of information on all 50 states policies and programs regarding medical home implementation. This site provides an interactive map in which you can view detailed information on each state’s current laws, partnerships, method of defining a medical home, financing structure, and measurement of quality improvement. Additionally, strategies for state implementation, archived webinars, and publications provide in-depth analysis of state-level policy on medical home implementation.

    New Tactics for Building Medical Homes in State Medicaid and CHIP Programs: The National Academy for State Health Policy (NASHP) has worked with a group of eight states to develop medical home programs. This December 2011 report highlights a variety of their achievements in the areas of forming partnerships, defining and recognizing medical homes, reforming payment, supporting practices, and measuring progress.

    Measurement of Medical Home Initiatives: Use of Claims-Based Data for Quality and Cost Evaluation: Evaluation of the impact of medical home implementation, on quality of care and cost of care delivery, is essential to quality improvement and future funding opportunities. NASHP examined the usefulness of claims-based data to evaluate medical home implementation in Oklahoma and Rhode Island. Examination of claims-based data, in conjunction with patient and provider surveys was used to provide a comprehensive evaluation quality and cost of care. Recommendations, including strengths and limitations of each method of evaluation, are included to guide future evaluation criteria in this report.

    Collaboration of Medicaid, CHIP and Title V Programs to Support Medical Home Initiatives: Interagency collaboration to support systems of care for all individuals is essential to improving the quality of care and reducing health care costs. Collaboration between Medicaid, CHIP, and Title V programs provides evidence for building partnerships across multiple agencies and engaging patient-provider partnerships. Best practices and policy considerations are outlined in this NASHP report.

    Role of Federally Qualified Health Centers in State-led Medical Home Collaboratives: This publication by the National Academy for State Health Policy (NASHP) looks into the role of health centers in PCMH collaboratives led by each state. PDF: 362 KB

    AAP’s Medical Home State Pages: This section of the NCMHI Web site includes information on state pediatric medical home initiatives, key contacts, partners, and related grant activities and initiatives.

    PCPCC’s Pilots and Demonstrations: The Patient-Centered Primary Care Collaborative has a database of information from public and private entities facilitating medical home initiative projects across the country.

    The Patient-Centered Medical Home’s Impact on Cost and Quality, Annual Review of Evidence, 2013-2014. View this report put together by the Patient-Centered Primary Care Collaborative that provides a summary of PCMH initiatives across the country, including cost and quality outcomes data.


    Medical Home Resources for Practices

    AAP and NCMHI’s 2015 Medical Home Webinar Series: The American Academy of Pediatrics (AAP) and its National Center for Medical Home Implementation (NCMHI) hosted a free three-part webinar series March through May 2015 focusing on patient- and family- centered care coordination and its benefits for children, families, and clinicians.

    Building Your Medical Home: An Introduction to Pediatric Primary Care Transformation: Brought to you by the National Center for Medical Home Implementation, this online resource guide provides support, tools, and resources to pediatric practices as they begin and work to sustain their medical home transformation process.  The resource guide provides strategies for self-assessment and measurement of quality improvement throughout the transformation process.

    AHRQ’s Patient-Centered Medical Home (PCMH) Measurement Module at Patient Level: The Agency for Healthcare Research and Quality (AHRQ) has developed a patient-level survey module—Patient-Centered Medical Home Module for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. This survey asks parents to evaluate their experiences at their most recent office visit.

    Measuring Medical Homes: Tools to Evaluate the Pediatric Patient and Family-Centered Medical Home: This monograph developed by the National Center for Medical Home Implementation presents various tools available and in use to identify, recognize, and evaluate a practice as a pediatric medical home. Because no one tool is recognized as the de facto tool to assess pediatric practices, a review of the relative merits of existing tools will help inform purchasers, payers, providers, and patients in evaluating pediatric practices.

    Medical Home Recognition Programs: Several organizations have developed or in the process of developing programs that recognize and/or accredit various health care organizations as medical homes according to specified sets of standards, including:
              National Committee for Quality Assurance (NCQA)
              Utilization Review Accreditation Commission (URAC)
              Joint Commission
              Accreditation Association for Ambulatory Health Care (AAAHC)


    Medical Home Resources for Families

    NCMHI tools and resources for families: This page includes tools, resources, and links to information that will assist families in successfully partnering with their child’s medical home. Included are four newly released plain language fact sheets for families that provide an overview of provisions of the ACA that benefit children and youth with special health care needs.

    Family Voices’ Family Centered Care Self-Assessment Tool: For Families and User's Guide: Family-centered care is a key aspect of quality in health care for children, youth and their families. This tool developed by Family Voices, can be used by families to assess their own skills and strengths, the care their children and youth receive, and to engage in discussions within health care settings and with policy makers about ways to improve health care services and supports.

    Child Version of the CAHPS Clinician and Group Visit Survey: The Visit Survey asks patients to report on their experiences with providers and office staff at their most recent visit to a doctor's office. The CAHPS Clinician and Group Child Visit Survey 2.0 can be used to assess the experiences of children and their parents during the child’s most recent visit with a provider.

    National Partnership for Women & Families’ Medical Home Principles: The National Partnership for Women & Families and broad coalition of more than 25 of the nation's leading consumer, labor and health care advocacy groups developed a set of principles designed to help health care providers, lawmakers, employers, and health plans consider consumer interests as they develop delivery system reforms such as the “medical home."

    How Consumer Advocates Can Get Involved: Steps You Can Take to Ensure the Medical Home is Patient-Centered: The National Partnership for Women & Families and a broad coalition of more than 25 of the nation's leading consumer, labor and health care advocacy groups developed a set of principles designed to help health care providers, lawmakers, employers, and health plans consider consumer interests as they develop delivery system reforms such as the "medical home." PDF: 119 KB

    Families Partnering with Providers: A 7-page booklet of tips on communicating with a child's health care providers: Preparing For An Office Visit, Talking With Your Child's Provider, Learning More and Helping Your Provider Help Other Families.

    CAHMI’s Well-Visit Planner: Engaging Parents as Partners to Customize and Improve Well Child Care for Young Children and their Families: Developed by the Child and Adolescent Health Measurement Initiative (CAHMI) and the Data Resource Center (DRC), this evidence-based tool was designed to customize, tailor and improve the quality of well-child care for young children. It engages parents as proactive partners in planning and conducting well-child visits using a simple three-step process. The Well-Visit Planner also has the capacity to integrate clinically-relevant information directly into and electronic health record (EHR).