Becoming a Medical Home: Implementation Guides


The patient-centered medical home is a model of primary care that can improve health care quality as well as clinicians’, staff members’, and patients’ experiences. The model can also increase efficiency. As part of the Commonwealth Fund–supported Safety Net Medical Home Initiative, Qualis Health and the MacColl Institute for Healthcare Innovation have identified eight key strategies that primary care sites can implement to become patient-centered medical homes. A set of implementation guides are available to help primary care providers put these strategies into practice in order to expand access to care, coordinate care, and better engage patients.

The Issue

Recent studies show that most primary care practices do not meet the functional requirements of a patient-centered medical home. While the Patient Centered Primary Care Collaborative’s Joint Principles for a Patient-Centered Medical Home outline the core components of the medical home model, providers need assistance on how to put these principles into practice. Based on the experiences of 65 safety net primary care sites that are working to become medical homes, Qualis Health and the MacColl Institute for Healthcare Innovation have developed concrete definitions of the changes needed as well as implementation guides to assist practices in becoming patient-centered medical homes.

Target Audience

Primary care practices

The Intervention

The Qualis/MacColl team identified eight key strategies, or “change concepts,” that serve as the framework for patient-centered medical home implementation. They also developed 16 implementation guides to help primary care providers put those concepts into practice:

  1.  Engaged Leadership
    a. Strategies for Guiding PCMH Transformation From Within
  2. Empanelment
    a. Establishing Patient-Provider Relationships
    b. Assigning and Managing Panels in a Patient-Centered Medical Home
  3. Continuous and Team-Based Healing Relationships
    a. Improving Patient Care Through Teams
    b. Elevating the Role of the Medical/Clinical Assistant: Maximizing Team-Based Care in the Patient-Centered Medical Home
    c. Redefining Staff Roles: Where to Start
  4. Patient-Centered Interactions
    a. Patient-Centered Interactions Part 1: Measuring Patient Experience
    b. Patient-Centered Interactions Part 2: Engaging Patients in their Health and Health Care
    c. Patient-Centered Interactions Part 3: Communicating to Improve the Patient-Centered Experience
  5. Quality Improvement Strategy
    a. Quality Improvement Strategy Part 2: Optimizing Health Information Technology for Patient-Centered Medical Homes
    b. Optimizing Health Information Technology for Patient-Centered Medical Homes
  6. Enhanced Access
    a. Enhanced Access: Providing the Care Patients Need, When They Need It
  7. Care Coordination
    a. Care Coordination: Reducing Care Fragmentation in Primary Care
    b. Strategies to Reduce Avoidable Emergency Department Use
  8. Organized, Evidence-Based Care
    a. Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations
    b. Improving Care for Complex Patients: The Role of the RN Care Manager

Each guide defines the strategy and provides step-by-step instructions on how to implement it. The guides also offer additional resources, including tools, journal articles, and examples of mentor sites with contact information.

For More Information

Visit the Safety Net Medical Home Initiative Web site at


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