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IMPROVING PATIENT CARE

The Patient-Centered Medical Home: A Systematic Review FREE

George L. Jackson, PhD, MHA; Benjamin J. Powers, MD, MHS; Ranee Chatterjee, MD, MPH; Janet Prvu Bettger, ScD; Alex R. Kemper, MD, MPH, MS; Vic Hasselblad, PhD; Rowena J. Dolor, MD, MHS; R. Julian Irvine, MCM; Brooke L. Heidenfelder, PhD; Amy S. Kendrick, RN, MSN; Rebecca Gray, DPhil; and John W. Williams Jr., MD, MHS
[+] Article and Author Information

This article was published at www.annals.org on 27 November 2012.


From Durham Veterans Affairs Medical Center and Duke University Schools of Medicine and Nursing, Durham, North Carolina.

Disclaimer: The authors of this report are responsible for its content. Statements in the report should not be construed as endorsements by AHRQ or the U.S. Department of Health and Human Services or necessarily reelections of the position or policy of the Department of Health and Human Services, Department of Veterans Affairs, or the United States government.

Acknowledgment: The authors thank Christine Chang, MD, MPH; Janice Genevro, PhD, MSW; and Kathryn McDonald, MM, for their suggestions on improving the clarity of the AHRQ Evidence Report on which this article is based; and Connie Schardt, MSLS, for help with the literature search and retrieval.

Grant Support: This project was funded under contract 290-2007-10066-I from AHRQ, U.S. Department of Health and Human Services, as part of the series “Closing the Quality Gap: Revisiting the State of the Science.”

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1295.

Requests for Single Reprints: George L. Jackson, PhD, MHA, Division of General Internal Medicine, Duke University School of Medicine, 307 Trent Drive, DUMC 3322, Durham, NC 27710; e-mail, george.l.jackson@duke.edu.

Current Author Addresses: Dr. Jackson: Durham Veterans Affairs Medical Center, HSR&D Service (152), 508 Fulton Street, Durham, NC 27705

Dr. Powers: 520 South Eagle Road, Suite 3102, Meridian, IA 83642

Dr. Chatterjee: Duke University, 5832 Fayetteville Road, Suite 113, Durham, NC 27713

Dr. Prvu Bettger: Duke University, 307 Trent Drive, DUMC 3322, Durham, NC 27710

Drs. Kemper, Dolor, Gray, and Heidenfelder; Mr. Irvine; and Ms. Kendrick: Duke University Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705

Dr. Hasselblad: 3534 Bay Island Circle, Jacksonville Beach, FL 32250

Dr. Williams: Duke University School of Medicine, 411 West Chapel Hill Street, Suite 500, Durham, NC 27701

Author Contributions: Conception and design: G.L. Jackson, B.J. Powers, R.J. Dolor, A.S. Kendrick, J.W. Williams.

Analysis and interpretation of the data: G.L. Jackson, B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, V. Hasselblad, R.J. Dolor, J.W. Williams.

Drafting of the article: G.L. Jackson, B.J. Powers, J. Prvu Bettger.

Critical revision of the article for important intellectual content: B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, R.J. Dolor, B.L. Heidenfelder, J.W. Williams.

Final approval of the article: G.L. Jackson, B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, R.J. Dolor, B.L. Heidenfelder, A.S. Kendrick, J.W. Williams.

Provision of study materials or patients: A.S. Kendrick.

Statistical expertise: V. Hasselblad.

Obtaining of funding: R.J. Dolor, J.W. Williams.

Administrative, technical, or logistic support: R.J. Irvine, B.L. Heidenfelder, A.S. Kendrick, R. Gray.

Collection and assembly of data: G.L. Jackson, B.J. Powers, R. Chatterjee, J. Prvu Bettger, A.R. Kemper, R.J. Dolor, R.J. Irvine, B.L. Heidenfelder, A.S. Kendrick, J.W. Williams.


Ann Intern Med. 2013;158(3):169-178. doi:10.7326/0003-4819-158-3-201302050-00579
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Background: The patient-centered medical home (PCMH) describes mechanisms for organizing primary care to provide high-quality care across the full range of individuals' health care needs. It is being widely implemented by provider organizations and third-party payers.

Purpose: To describe approaches for PCMH implementation and summarize evidence for effects on patient and staff experiences, process of care, and clinical and economic outcomes.

Data Sources: PubMed (through 6 December 2011), Cumulative Index to Nursing & Allied Health Literature, and the Cochrane Database of Systematic Reviews (through 29 June 2012).

Study Selection: English-language trials and longitudinal observational studies that met criteria for the PCMH, as defined by the Agency for Healthcare Research and Quality, and included populations with multiple conditions.

Data Extraction: Information on study design, populations, interventions, comparators, financial models, implementation methods, outcomes, and risk of bias were abstracted by 1 investigator and verified by another.

Data Synthesis: In 19 comparative studies, PCMH interventions had a small positive effect on patient experiences and small to moderate positive effects on the delivery of preventive care services (moderate strength of evidence). Staff experiences were also improved by a small to moderate degree (low strength of evidence). Evidence suggested a reduction in emergency department visits (risk ratio [RR], 0.81 [95% CI, 0.67 to 0.98]) but not in hospital admissions (RR, 0.96 [CI, 0.84 to 1.10]) in older adults (low strength of evidence). There was no evidence for overall cost savings.

Limitation: Systematic review is challenging because of a lack of consistent definitions and nomenclature for PCMH.

Conclusion: The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes, but current evidence is insufficient to determine effects on clinical and most economic outcomes.


The United States spends a greater proportion of its gross domestic product on health care than any other country in the world (1) yet often fails to provide high-quality and efficient care (26). At the same time, satisfaction among primary care physicians has waned amid the increasing demands of office-based practice (7). There has been growing concern that current models of primary care will not be sustainable for meeting the health care needs of the population.

The patient-centered medical home (PCMH) is a model of primary care transformation that seeks to meet the health care needs of patients and to improve patient and staff experiences, outcomes, safety, and system efficiency (811). The term “medical home” was first used by the American Academy of Pediatrics in 1967 to describe the concept of a single centralized source of care and medical record for children with special health care needs (12). Building on other widely promulgated efforts, such as the chronic care model (13), the current concept of PCMH has been greatly expanded and is based on 40 years of previous efforts to redesign primary care to provide the highest quality of care possible (1415).

As defined by physician and consumer groups, the core principles of the PCMH are the following: wide-ranging, team-based care; patient-centered orientation toward the whole person; care that is coordinated across all elements of the health care system and the patient's community; enhanced access to care that uses alternative methods of communication; and a systems-based approach to quality and safety (9). Although these principles are frequently cited in relation to PCMH, it should be recognized that specific PCMH definitions vary widely, reflecting the rapid expansion of the use of PCMH concepts in the past decade (16). This review was conducted as part of the Agency for Healthcare Quality and Research's (AHRQ's) “Closing the Quality Gap: Revisiting the State of the Science” series (17) and sought to describe how studies conducted to date have implemented PCMH and to evaluate the current evidence of the effect of PCMH interventions on patient, staff, and economic outcomes.

A technical report that details our methods and results for all 4 original research questions is available at www.ahrq.gov (18). Topics for the “Closing the Quality Gap” series were solicited from the portfolio leads at AHRQ. Investigators at the Duke Evidence-based Practice Center refined the research questions through discussions with the Stanford Evidence-based Practice Center, which coordinated the series, and with representatives of AHRQ. A panel of experts knowledgeable in PCMH principles provided input during the protocol development process.

Research Questions

The present review addresses 3 of the 4 research questions included in the original AHRQ evidence report (omitting a horizon scan of ongoing research) (18). We sought to describe PCMH interventions that have been studied in the peer-reviewed literature and the effectiveness of PCMH in studies that included a comparison group. Specifically, we addressed the following questions:

1. In published, primary care–based evaluations of comprehensive PCMH interventions, what individual PCMH components have been implemented?

2. In published, primary care–based evaluations of comprehensive PCMH interventions, what financial models and implementation strategies have been used to support uptake?

3. In published, primary care–based evaluations of comprehensive PCMH interventions, what are the effects of the PCMH on patient and staff experiences, process of care, clinical outcomes, and economic outcomes?

Definition of PCMH

We created an operational definition of a PCMH intervention based on the AHRQ's definition of PCMH (8). To be considered a PCMH intervention required the following: 1) team-based care, 2) having at least 2 of 4 elements focused on how to improve the entire organization of care (enhanced access, coordinated care, comprehensiveness, systems-based approach to improving quality and safety), 3) a sustained partnership, and 4) having an intervention that involves structural changes to the traditional practice. Interventions that did not use the term “medical home” but that met this definition were categorized as “functional PCMH” interventions. Specific items included in the definition can be found in Figure 1.

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Figure 1.

Definition of the patient-centered medical home.

Based on the Agency for Healthcare Research and Quality's definition (8). Includes each of categories 1 through 4.

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Data Sources and Searches

We searched PubMed, Cumulative Index to Nursing & Allied Health Literature, and the Cochrane Database of Systematic Reviews. Our search strategy used the National Library of Medicine's Medical Subject Headings keyword nomenclature and text words for the medical home and related concepts and for eligible study designs. We included studies published in English and indexed from database inception through 29 June 2012. The exact search strings are given in the Appendix. We supplemented these electronic searches with a manual search of citations from a set of key primary and review articles (1926).

Study Selection

To be included in the review, studies had to 1) be peer-reviewed; 2) have interventions that met the preceding PCMH definition; 3) have interventions delivered to patient populations representing multiple diseases (that is, no single-disease care management studies); 4) be conducted among adult or child primary care patients; 5) have follow-up of at least 6 months; and 6) be a randomized, controlled trial or an observational study. Studies describing PCMH interventions in the published literature did not require a comparison group. However, studies examining the effectiveness of PCMH were required to have such a group.

Two investigators independently reviewed each title and abstract for potential relevance to the research questions; articles included by either investigator underwent full-text screening. At the full-text screening stage, 2 investigators independently reviewed the full text of each article for inclusion. Disagreements were resolved through review and discussion among investigators.

Data Extraction and Quality Assessment

One researcher abstracted the data, and a second over-read the abstracted data to check for accuracy and completeness. Disagreements were resolved by consensus or by obtaining a third reviewer's opinion if consensus could not be reached by the first 2 investigators. To aid in reproducibility and standardization of data collection, researchers received data abstraction instructions directly on each form created specifically for this project within the DistillerSR software program (Evidence Partners, Manotick, Ontario, Canada). Abstraction forms were pilot-tested with a sample of included articles to ensure that all relevant data elements were captured and that there was consistency and reproducibility across abstractors. Data abstraction forms included information on study design, study population, interventions, comparators, financial models, implementation methods, study outcomes, and study quality. Results of interest examined for PCMH effectiveness included patient experiences, staff experiences, process of care, clinical outcomes, and economic outcomes.

We evaluated the quality/risk of bias of individual studies addressing the effectiveness question by using the approach described in AHRQ's “Methods Guide for Effectiveness and Comparative Effectiveness Reviews” (hereafter called the “Methods Guide”) (27) by applying predefined criteria for methodological quality and adequacy of reporting for each study type to arrive at a summary judgment of the study's quality (good, fair, or poor).

Data Synthesis and Analysis

Studies were categorized into those that explicitly tested the PCMH model and those that met our functional definition for PCMH but did not use the terms “PCMH” or “medical home”; we refer to the latter as “functional PCMH” studies. Outcomes described below were broadly categorized as relating to the following: 1) the quality of both patient and staff experiences with care, 2) clinical quality (that is, provision of evidence-based care and health outcomes), or 3) the economic effect of PCMH initiatives. Because of the wide variability in recommended measures for evaluating PCMH, we analyzed outcomes that were reported across studies, focusing on those collected by using validated instruments or methods. With the exception of inpatient and emergency department utilization, studies were too heterogeneous in design and in outcomes reporting for quantitative syntheses. We used a random-effects model using the DerSimonian–Laird method (28) to compute summary estimates of effect for hospitalizations and emergency department visits for the subset of studies that used randomized, controlled trial designs. Summary estimates were calculated by using Comprehensive Meta-Analysis software, version 2 (Biostat, Englewood, New Jersey) and are reported as summary risk ratios (RRs).

For other outcomes, the study populations, designs, and outcomes were too variable for quantitative analysis. We computed effect sizes, represented as the standardized mean difference (SMD, a summary statistic that uses a common scale) (27), to aid in interpretation of the qualitative synthesis. The SMD is useful when studies assess the same outcome but with different measures or scales. The SMDs were calculated for each study by using the Hedges g (which corrects for small sample sizes) by subtracting (at posttest) the average score of the control group from the average score of the experimental group and dividing the result by the pooled standard deviations of the experimental and control groups (29). Beneficial effects are presented as positive effect sizes.

The strength of evidence for the highest-priority effectiveness outcomes was assessed by using the approach described in the Methods Guide (27, 30). In brief, the Methods Guide recommends assessment of 4 domains: risk of bias, consistency, directness, and precision. Additional domains are to be used when appropriate: coherence, dose–response association, impact of plausible residual confounders, strength of association (magnitude of effect), and publication bias. These domains were considered qualitatively and a summary rating was assigned, after discussion by 2 reviewers, as “high,” “moderate,” or “low” strength of evidence. In some cases, such ratings were impossible or imprudent to make (for example, when no evidence was available or when evidence on the outcome was too weak, sparse, or inconsistent to permit any conclusion to be drawn). In these situations, a grade of “insufficient” was assigned.

Role of the Funding Source

Funding was provided by AHRQ. Representatives of the funding source provided technical assistance during the conduct of the review and commented on draft versions of the full technical report. The funding source did not, however, directly participate in the literature search; determination of study eligibility criteria; data analysis; or interpretation, or preparation, review, or approval of the manuscript for publication. The AHRQ granted copyright assertion.

Study Selection

We identified 5731 citations from all sources. After applying inclusion and exclusion criteria at the title-and-abstract level, 768 full-text articles were retrieved and screened. Of these, 708 were excluded at the full-text screening stage, leaving 60 articles representing 31 unique peer-reviewed studies. Nineteen studies were comparative studies of the effects of PCMH; these 19, plus 12 noncomparative studies, described aspects of studied PCMH interventions. With 1 exception (31), all studies were rated as being of good or fair quality (Figure 2 and Appendix Tables 1, 2, and 3).

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Figure 2.

Summary of evidence search and selection.

CINAHL = Cumulative Index to Nursing & Allied Health Literature; PCMH = patient-centered medical home.

* All studies/articles included for effectiveness studies were also included in the analysis of PCMH intervention descriptions.

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Table Jump PlaceholderAppendix Table 1. 

Characteristics of Included Studies—Comparative Randomized, Controlled Trials (Questions 1–3)

Table Jump PlaceholderAppendix Table 2. 

Characteristics of Included Studies—Comparative Observational Studies (Questions 1–3)

Table Jump PlaceholderAppendix Table 3. 

Characteristics of Included Studies—Noncomparative Studies (Questions 2 and 3)

Implemented PCMH Components

The PCMH interventions tended to involve comprehensive changes in the delivery of primary care, with 24 of 31 studies describing interventions that included all 7 major PCMH components. However, studies varied greatly in the number and types of specific approaches used to implement these core components; overall, 51 different strategies or approaches were used (Appendix Table 4). The PCMH studies used more strategies than did functional PCMH studies. Most studies addressed chronic illness, preventive care needs, and acute care needs; used multidisciplinary teams that included a designated primary care provider and defined roles (such as who manages specific aspects of care); and coordinated care transitions (for example, follow-up of patients who have been hospitalized). Three quarters reported adding new staff (such as a case manager). All but 4 studies used strategies to enhance access, such as home or telephone visits, but no single strategy was used in most studies. Identifying high-risk patients and using evidence-based clinical guidelines, performance monitoring, and electronic health records were the most commonly used approaches to improving quality and safety (Appendix Table 4).

Table Jump PlaceholderAppendix Table 4. 

PCMH Components Implemented and Implementation Strategies Used (Questions 2 and 3)

Financial and Implementation Strategies

Implementation of PCMH requires significant restructuring for most primary care practices. Recognizing the increased range of services required, some definitions of the medical home include a financial component, but this was not a requirement for inclusion in our review. Among the 31 included studies, only 13 described aspects of their financial model, including fewer than half of the studies specifically designed to test PCMH. These studies used a variety of methods to fund PCMH implementation, including receipt of external study funding, capitation payments, enhanced fee-for-service, or a hybrid approach. Although not a PCMH-specific financial mechanism, it should be noted that most studies were conducted in integrated delivery systems, such as staff- or group-model HMOs, led by payer organizations, or conducted outside the United States. Little information is available on financial models for using PCMH principles in independent fee-for-service primary care practices.

Although it is likely that both organizational learning and implementation strategies are necessary for implementation of complex interventions (13, 32), we recognize that these concepts can overlap substantially. The most commonly used organizational learning strategy, applied in most studies (n = 19 of 24 studies reporting information on learning strategies), was a formal learning collaborative or collaborative program planning forums for practice team members to learn about PCMH or its components. For implementation, more than half of 20 studies reporting information on implementation strategies used audit and feedback, usually involving quality improvement methods. The largest trial found that facilitated PCMH was associated with better staff experience than nonfacilitated PCMH (33); facilitation was qualitatively shown to be important for PCMH implementation (34). This suggests that the effect of PCMH on practices may go beyond simply having the identified elements in place. The process of facilitation may also represent an important part of the process for making PCMH successful (Appendix Table 5).

Table Jump PlaceholderAppendix Table 5. 

Meta-analyses for Inpatient and Emergency Department Utilization Reported in Randomized, Controlled Trials

Effects of PCMH Interventions

Only 7 studies explicitly evaluated PCMH; an additional 12 studies evaluated functional PCMH interventions. Studies included both observational designs (n = 10) and randomized, controlled trials (n = 9). Older adults in the United States with multiple chronic conditions were the most commonly studied population (primary focus of 10 of the 19 studies). Most studies were conducted in integrated health care systems (10 of 19 studies). Studies varied widely in the range of outcomes reported and the specific measures used. With the exception of 1 study that examined facilitated versus nonfacilitated PCMH implementation (35), all studies compared PCMH interventions to usual care (Table 1).

Table Jump PlaceholderTable 1. 

Comparative Study Characteristics and Reported Outcomes

For most outcomes, the small number of studies conducted among children precluded formal comparison with studies conducted in adults. However, results in these 2 populations were similar. Table 2 summarizes the strength of evidence for each of the 5 outcome domains. Furthermore, Appendix Table 6 summarizes findings grouped by individual study.

Table Jump PlaceholderTable 2. 

Summary of the Strength of Evidence for Effects of PCMH

Table Jump PlaceholderAppendix Table 6. 

Reported Outcomes by Study

Patient and Staff Experiences

Patient-centered medical homes have the goal of improving the experience of the key partners in health care: patients and staff. In this domain, evidence suggests short-term (with 3 exceptions, 2 years or less) benefits of PCMH for both patient (3542) and staff experience (3536, 38). Moderate-strength evidence indicates that interventions meeting PCMH criteria are associated with small improvements in patient experiences, on both overall measures of patient satisfaction and measures of patient-reported or patient-perceived level of care coordination. These studies included a variety of patient populations, indicating broad applicability of this finding. Although less compelling than evidence related to patient experiences, some studies (low strength of evidence) support the hypothesis that primary care staff may be more satisfied in PCMH practices (3536, 38). Two of these were PCMH studies, and 1 evaluated a functional PCMH intervention. Two of the 3 studies were conducted in an older adult population; none was conducted in pediatric practices. Overall, relatively few practices and few clinicians have been involved in these studies, and these practices may not be representative of the wider primary care practices in the United States.

Clinical Quality

Clinical quality can be considered to encompass both the provision of evidence-based care processes and the resulting health outcomes. We categorized process-of-care outcomes into preventive services and chronic illness care services (3536, 40, 4247). Prioritization was given to generally accepted, guideline-recommended care processes. Our summary of clinical outcomes is divided into biophysical markers (3 studies), patient-reported health status (4 studies), and mortality (2 studies).

Evidence suggests that PCMH may improve care processes, especially for preventive services. This is based on a combination of moderate evidence of an effect for prevention services and insufficient evidence to evaluate effects on care for patients with chronic illness. Although results are mixed in terms of whether differences are statistically significant, the point estimates for all but 2 of the process-of-care comparisons are in the direction of the intervention. A lack of power may account for the lack of statistical significance for at least some of the differences. Although there is a possibility that PCMH may lead to more appropriate care, more research is needed to examine this possibility, especially in relation to chronic illness care.

Insufficient evidence is available to determine the effect of PCMH implementation on clinical outcomes. Only 1 of the studies had a stated goal of testing PCMH, and that study compared facilitated PCMH against nonfacilitated implementation (35). Most studies were conducted in an older adult population; none were conducted among children. Only 2 observational studies reported effects on biophysical markers, finding a higher rate of improved hemoglobin A1c and low-density lipoprotein cholesterol values in intervention patients (44) in 1 study and no difference in composite diabetes and coronary artery disease outcomes in another (42). Four studies examined effects on patient-reported health status. None of the 3 randomized, controlled trials (35, 41, 48) found a statistically significant benefit on health status, but the single observational study (31) found a lower rate of functional decline (31% vs. 49% of patients) at 1-year follow-up in older adults receiving functional PCMH care. In the older adult population, limited data show that PCMH may have a positive effect on mortality. A single good-quality observational study found a mortality benefit at 1 year that was no longer significant at 2 years (49). Two other studies (1 RCT, 1 observational) had non–statistically significant findings also in the direction of lower mortality (31, 41), pointing to the potential benefit of continuing to examine intensive PCMH-type interventions targeting frail seniors and the effect on mortality.

Economic Effects

The most studied potential effect of PCMH involves the hypothesis that PCMH interventions will reduce health care utilization and costs (36, 3841, 4345, 4752). Our summary of economic outcomes is divided into differences in inpatient utilization, emergency department utilization, and total costs. There is a low strength of evidence that PCMH does not lead to uniformly lower utilization of 2 areas hypothesized to be affected: inpatient and emergency department utilization. Moreover, total costs were not consistently decreased in the reviewed studies. The 5 randomized, controlled trials of functional PCMH interventions did not find a statistically significant effect on inpatient utilization (combined RR, 0.98 [95% CI, 0.86 to 1.12]) (38, 4041, 45, 47). Three of these trials reported on emergency department utilization (38, 4041), finding no effect (combined RR, 0.93 [CI, 0.72 to 1.20]), but the CI was wide. However, a subgroup analysis of the 2 trials among older adults (38, 41) pointed to the possibility of an association with lower emergency department utilization (combined RR, 0.81 [CI, 0.67 to 0.98]). These trial results are summarized in Appendix Table 5. In contrast to the trial results, 3 observational studies (1 each in a general adult population, older adults, and children) found small to moderately decreased inpatient and emergency department utilization (43, 50, 5354). With the exception of 1 subanalysis, no studies, including the 3 observational studies showing lower inpatient and emergency department utilization, reported statistically significant cost savings among PCMH patients during 6 to 24 months of follow-up. In fact, when program costs were considered, 1 good-quality trial and 1 fair-quality observational study reported greater total costs among PCMH intervention patients (43, 55). Despite these findings, 1 study, a subgroup analysis of expected cost differences among patients enrolled in the PCMH clinics of the Geisinger Health System, indicates that savings may occur with lengthy exposure to the PCMH system of greater than 1 year (56). This hypothesis may be taken up by future work in PCMH.

Although few studies have evaluated the effects of the PCMH, a moderately well-developed series of randomized, controlled trials and observational studies have tested interventions meeting the functional definition of the medical home. Moderately strong evidence suggests that the medical home has a small positive effect on patient experiences and small to moderate positive effects on preventive care services. Staff experiences are also improved by a small to moderate degree (low strength of evidence), but no study reported effects on staff retention. Current evidence is insufficient to determine effects on clinical and most economic outcomes. Given the relatively small number of studies directly evaluating the medical home and the evolving approaches to designing and implementing the medical home model, these findings should be considered preliminary (Table 2 and Figure 3).

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Figure 3.

PCMH take-home points.

PCMH = patient-centered medical home.

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It is not surprising that the approaches to implementing the various components of PCMH varied widely. Interventions explicitly developed from the PCMH model used more approaches than those simply meeting our operational definition of “functional PCMH.” As the evidence base expands, analyses of the relative effect of PCMH components will be important for clarifying the key approaches and could inform certifying agencies' criteria for medical home practices. Clinical practices and policymakers also need better information on the financial context and implementation strategies required for successful spread and sustainability of the PCMH model. Fewer than half of the studies included in this report described any new payment model, such as enhanced fee-for-service or additional per-member, per-month payments to PCMH practices. Further, there were no data on direct financial consequences to the practice implementing PCMH. This information—possibly through the mechanism of detailed case studies—could inform implementation efforts and the design of enhanced payment mechanisms for medical home practices.

Our review identified important gaps in currently available evidence on the effects of PCMH. Most studies evaluated effects in older adults with multiple chronic illnesses; few studies were conducted in pediatric or general adult primary care populations. Effects on quality indicators for chronic illness care and on clinical outcomes are uncertain. These are among the most important outcomes to patients, clinicians, and policymakers. Other gaps in evidence include the absence of data on staff retention and unintended consequences. If the improvements in staff experiences translate into improved staff retention and greater attractiveness of primary care practice, then PCMH would have met 1 of its goals. The potential for unanticipated consequences has not received much attention in the literature and was not evaluated in any of our included studies.

A horizon scan conducted for this review (results reported in AHRQ evidence-synthesis report) (18) identified 31 ongoing PCMH studies that are broadly representative of the U.S. health care system, both in geography and in the complexity of private and public health care payers and delivery networks. Many of these studies are being done in cooperation with payer organizations, and most are expected to be completed in the next 2 years. As a result, the evidence base related to PCMH will soon be greatly expanded. We encourage investigators to report the interventions in detail (that is, specific tasks, roles, and activities; detail on study setting; information on how the program is financed; and detail on how the team encouraged implementation), adjust for clustering when appropriate, report meaningful quality indicators for chronic illness (both processes and clinical outcomes), and provide data on the effect of PCMH on staff (including both survey data and staff turnover). We also encourage long-term follow-up of results. Outcomes examined in this report rarely had follow-up periods longer than 2 years. For certain outcomes, data from the electronic health record may provide the ability to examine long-term outcomes after the conclusion of formal funded studies.

Our review has important limitations. The PCMH is a model of care with considerable flexibility, not a narrowly defined intervention or manualized protocol. There is no standard nomenclature for components of the PCMH model. Further, various professional and patient organizations have proposed multiple definitions of the PCMH model (16). We developed an operational definition derived from the AHRQ definition of the medical home (8), which does not require an enhanced payment model. Because we used this definition, our review was more inclusive of studies that tested the critical principles that embody the Institute of Medicine concept of patient-centered care (57). However, greater inclusivity came with the trade-off of greater variability in study interventions. Although our search of ClinicalTrials.gov and other research databases did not suggest completed but unpublished studies, publication and selective outcomes reporting remain possible and could bias results. Related to this issue is the fact that PCMH models may be evaluated by organizations that do not routinely produce publications for peer review (such as consulting firms). Such results would then not be reflected in an analysis such as ours. Finally, heterogeneity in study designs, populations, and outcomes meant that standard quantitative summary methods were generally not possible.

The PCMH model is being widely implemented in various health care systems and includes key principles that are encouraged in the Affordable Care Act and required for recognition as an Accountable Care Organization (5859). Despite this impetus for implementation and agreement on broad concepts, such as enhancing team-based care and patient access, the exact approaches to PCMH implementation vary broadly. This review indicated that PCMH is a conceptually sound approach to organizing patient care and appears to hold promise, especially for improving the experiences of patients and staff involved in the health care system. Evidence points to the possibility of improved care processes; however, ongoing and future studies are needed to determine whether these improvements translate into improved clinical outcomes or economic benefit. Although implementing the PCMH principles is something to be considered by organizations seeking to enhance patient experience and quality of care, no menu is yet available for specific actions that are most likely to enhance benefits to patients, staff, and organizations.

Appendix: Exact Search Strings

The PubMed search strategies described here (updated search date 29 June 2012) were adapted for use in the Cumulative Index to Nursing & Allied Health Literature database (CINAHL, search date 29 June 2012) and the Cochrane Database of Systematic Reviews (CDSR, search date 29 June 2012–30 March 2011). Results from searches A and B, described below, were combined to form the full citation set.

Search A (29 June 2012)

1. “medical home” OR “health-care home” OR “advanced primary care” OR “guided care” OR “patient aligned care team” OR “pcmh[tiab]

2. Clinical[tiab] AND trial[tiab]

3. clinical trials[MeSH] OR clinical trial[PT] OR random*[tiab] OR random allocation[MeSH] OR “time points”[tiab]

4. “time series AND interrupt[tiab]

5. pretest[tiab] OR pre-test[tiab] OR posttest[tiab]

6. quasi-experiment*[tiab] OR quasiexperiment*[tiab] OR quasirandom*[tiab] OR quasi-random*[tiab] OR quasi-control*[tiab] OR quasicontrol*[tiab]

7. cluster[tiab] AND trial[tiab]

8. (study[tiab] AND continuing[tiab] OR follow-up[tiab] OR longitudinal[tiab] OR demonstration[tiab] OR intervention[tiab])

9. treatment outcome[MeSH] OR multicenter study[PT] OR comparative study[PT] OR clinical trial OR comparative[tiab] OR comparison[tiab] OR matched[tiab] OR “Evaluation Studies as Topic”[MeSH:noexp] OR ““Program Evaluation”[MeSH] OR “Validation Studies as Topic”[MeSH] OR “Multicenter Studies as Topic”[MeSH] OR “Controlled Clinical Trials as Topic”[MeSH:noexp] OR “evaluation studies”[PT]

10. #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9

11. #1 AND #10

Limits:

Language: English

Not: Editorial, Letter, Practice Guideline

Search B (29 June 2012)

1. “Patient-Centered Care”[MeSH] OR “Delivery of Health Care, Integrated”[MeSH] OR “Patient Care Team”[MeSH:noexp] OR “chronic care model” or “system redesign” OR “systems redesign” OR “disease management”[mh] OR “patient care management”[MeSH:noexp] OR collaboratives

2. “Primary Health Care”[Mesh:noexp] OR “family practice”[mesh] OR “internal medicine”[Mesh] OR “physicians, family”[mesh] OR geriatrics[Mesh] OR “primary care”[tiab] OR chronic disease[mh] OR “ambulatory Care”[Mesh] OR “Health Services for the Aged”[MeSH] OR “Community networks”[mesh] OR “pediatrics”[Mesh] OR “Child Health Services”[Mesh] OR “Health Care Coalitions”[Mesh] OR (child*[tiab] AND special[tiab] AND health*[tiab]) OR “diabetes mellitus”[Mesh] OR “diabetes mellitus”[tiab] OR “depressive disorder”[Mesh] OR “major depression”[tiab] OR “heart failure”[Mesh] OR “heart failure”[tiab] OR “coronary disease”[Mesh] OR “angina pectoris”[Mesh:noexp] OR hypertension[Mesh] OR hypertension[tiab] OR hyperlipidemias[Mesh] OR hyperlipidemia[tiab]

3. clinical[tiab] AND trial[tiab]) OR clinical trials[MeSH] OR clinical trial[PT] OR random*[tiab] OR random allocation[MeSH] OR “time points”[tiab] OR (“time series” AND interrupt[tiab]) OR pretest[tiab] OR pre-test[tiab] OR post-test[tiab] OR posttest[tiab]

4. quasi-experiment*[tiab] OR quasiexperiment*[tiab] OR quasirandom*[tiab] OR quasi-random*[tiab] OR quasi-control*[tiab] OR quasicontrol*[tiab]

5. (cluster[tiab] AND trial[tiab]) OR (study[tiab] AND continuing[tiab] OR follow-up[tiab] OR longitudinal[tiab] OR demonstration[tiab] OR intervention[tiab])

6. treatment outcome[Mesh] OR multicenter study[pt] OR comparative study[pt] OR clinical trial OR comparative[tiab] OR comparison[tiab] OR matched[tiab] OR “Evaluation Studies as Topic”[Mesh:noexp] OR “Program Evaluation”[Mesh] OR “Validation Studies as Topic”[Mesh] OR “Multicenter Studies as Topic”[Mesh] OR “Controlled Clinical Trials as Topic”[Mesh:noexp] OR “evaluation studies”[pt]

7. #3 OR #4 OR #5 OR #6

8. #1 AND #2 AND #7

Limits:

Language: English

Not: Editorial, Letter, Practice Guideline

Not: Citations from Search A

Martin A, Lassman D, Whittle L, Catlin A, National Health Expenditure Accounts Team. Recession contributes to slowest annual rate of increase in health spending in five decades. Health Aff (Millwood). 2011; 30:11-22.
PubMed
CrossRef
 
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348:2635-45.
PubMed
CrossRef
 
Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998–1999 to 2000–2001. JAMA. 2003; 289:305-12.
PubMed
CrossRef
 
Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med. 2006; 144:465-74.
PubMed
CrossRef
 
Grant RW, Buse JB, Meigs JB. Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change. Diabetes Care. 2005; 28:337-442.
PubMed
CrossRef
 
Nolte E, McKee CM. Measuring the health of nations: updating an earlier analysis. Health Aff (Millwood). 2008; 27:58-71.
PubMed
 
Bodenheimer T. Primary care—will it survive? N Engl J Med. 2006; 355:861-4.
PubMed
CrossRef
 
Agency for Healthcare Research and Quality.  Patient Centered Medical Home Resource Center. Accessed at http://pcmh.ahrq.gov/ on 24 January 2011.
 
Scholle S, Torda P, Peikes D, Han E, Genevro J.  Engaging Patients and Families in the Medical Home (Prepared by Mathematica Policy Research under contract no. HHSA290200900019ITO2.) AHRQ Publication no. 10-0083-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2010.
 
Moreno L, Peikes D, Krilla A.  Necessary But Not Sufficient: The HITECH Act and Health Information Technology's Potential to Build Medical Homes. (Prepared by Mathematica Policy Research under contract no. HHSA290200900019ITO2.) AHRQ Publication no. 10-0080-EF. Rockville, MD: Agency for Healthcare Research and Quality; June 2010.
 
Stange KC, Nutting PA, Miller WL, Jaen CR, Crabtree BF, Flocke SA, et al. Defining and measuring the patient-centered medical home. J Gen Intern Med. 2010; 25:601-12.
PubMed
CrossRef
 
Sia C, Tonniges TF, Osterhus E, Taba S. History of the medical home concept. Pediatrics. 2004; 113:1473-8.
PubMed
 
Wagner EH, Glasgow RE, Davis C, Bonomi AE, Provost L, McCulloch D, et al. Quality improvement in chronic illness care: a collaborative approach. Jt Comm J Qual Improv. 2001; 27:63-80.
PubMed
 
Kilo CM, Wasson JH. Practice redesign and the patient-centered medical home: history, promises, and challenges. Health Aff (Millwood). 2010; 29:773-8.
PubMed
CrossRef
 
Carrier E, Gourevitch MN, Shah NR. Medical homes: challenges in translating theory into practice. Med Care. 2009; 47:714-22.
PubMed
CrossRef
 
Vest JR, Bolin JN, Miller TR, Gamm LD, Siegrist TE, Martinez LE. Medical homes: “where you stand on definitions depends on where you sit”. Med Care Res Rev. 2010; 67:393-411.
PubMed
CrossRef
 
Agency for Healthcare Research and Quality.  Closing the Quality Gap: Revisiting the State of the Science—Series Overview. 23 June 2011. Accessed at www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=715 on 13 March 2012.
 
Williams JW, Jackson GL, Powers BJ, Chatterjee R, Prvu Bettger J, Kemper AR, et al.  Closing the Quality Gap: Revisiting the State of the Science. Evidence Report no. 208. (Prepared by the Duke Evidence-based Practice Center under contract no. 290-2007-10066-I.) Rockville, MD: Agency for Healthcare Research and Quality; July 2012. Accessed at www.effectivehealthcare.ahrq.gov/reports/final.cfm.
 
Chapman AL, Morgan LC, Gartlehner G. Semi-automating the manual literature search for systematic reviews increases efficiency. Health Info Libr J. 2010; 27:22-7.
PubMed
CrossRef
 
Bitton A, Martin C, Landon BE. A nationwide survey of patient centered medical home demonstration projects. J Gen Intern Med. 2010; 25:584-92.
PubMed
 
Homer CJ, Klatka K, Romm D, Kuhlthau K, Bloom S, Newacheck P, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics. 2008; 122:922-37.
PubMed
CrossRef
 
Rosenthal TC. The medical home: growing evidence to support a new approach to primary care. J Am Board Fam Med. 2008; 21:427-40.
PubMed
CrossRef
 
Robert Graham Center.  The patient centered medical home: history, seven core features, evidence and transformational change. 2007. Accessed at www.graham-center.org/online/graham/home/publications/monographs-books/2007/rgcmo-medical-home.html on 21 September 2010.
 
Grumbach K, Bodenheimer T, Grundy P.  The outcomes of implementing patient-centered medical home interventions: A review of the evidence on quality, access and costs from recent prospective evaluation studies, August 2009. Accessed at www.pcpcc.net/files/evidenceWEB%20FINAL%2010.16.09_1.pdf on 21 September 2010.
 
Ginsburg P, Maxfield M, O'Malley A, Peikes D, Pham H.  Making medical homes work: moving from concept to practice. December 2008. Accessed at http://hschange.org/CONTENT/1030/? on 21 September 2010.
 
DePalma JA. Evidence to support medical home concept for children with special health care needs. Home Health Care Management & Practice. 2007; 19:473-5.
 
Agency for Healthcare Research and Quality.  Methods guide for effectiveness and comparative effectiveness reviews. Rockville, MD: Agency for Healthcare Research and Quality. Accessed at www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=318 on 31 October 2011.
 
DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986; 7:177-88.
PubMed
 
Durlak JA. How to select, calculate, and interpret effect sizes. J Pediatr Psychol. 2009; 34:917-28.
PubMed
 
Owens DK, Lohr KN, Atkins D, Treadwell JR, Reston JT, Bass EB, et al. AHRQ series paper 5: grading the strength of a body of evidence when comparing medical interventions-Agency for Healthcare Research and Quality and the Effective Health Care Program. J Clin Epidemiol. 2010; 63:513-23.
PubMed
CrossRef
 
Hebert R, Durand PJ, Dubuc N, Tourigny A. Frail elderly patients. New model for integrated service delivery. Can Fam Physician. 2003; 49:992-7.
PubMed
 
Jackson GL, Powell AA, Ordin DL, Schlosser JE, Murawsky J, Hersh J, et al. Developing and sustaining quality improvement partnerships in the VA: the Colorectal Cancer Care Collaborative. J Gen Intern Med. 2010; 25:Suppl 138-43.
PubMed
 
Nutting PA, Crabtree BF, Stewart EE, Miller WL, Palmer RF, Stange KC, et al. Effect of facilitation on practice outcomes in the National Demonstration Project model of the patient-centered medical home. Ann Fam Med. 2010; 8:Suppl 1S33-44; S92.
PubMed
 
Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaen CR. Journey to the patient-centered medical home: a qualitative analysis of the experiences of practices in the National Demonstration Project. Ann Fam Med. 2010; 8:Suppl 1S45-56; S92.
PubMed
 
Jaen CR, Crabtree BF, Palmer RF, Ferrer RL, Nutting PA, Miller WL, et al. Methods for evaluating practice change toward a patient-centered medical home. Ann Fam Med. 2010; 8:Suppl 1S9-20; S92.
PubMed
 
Reid RJ, Fishman PA, Yu O, Ross TR, Tufano JT, Soman MP, et al. Patient-centered medical home demonstration: a prospective, quasi-experimental, before and after evaluation. Am J Manag Care. 2009; 15:71-87.
PubMed
 
Farmer JE, Clark MJ, Drewel EH, Swenson TM, Ge B. Consultative care coordination through the medical home for CSHCN: a randomized controlled trial. Matern Child Health J. 2011; 15:1110-18.
PubMed
CrossRef
 
Boult C, Reider L, Frey K, Leff B, Boyd CM, Wolff JL, et al. Early effects of “Guided Care” on the quality of health care for multimorbid older persons: a cluster-randomized controlled trial. J Gerontol A Biol Sci Med Sci. 2008; 63:321-7.
PubMed
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Boyd CM, Boult C, Shadmi E, Leff B, Brager R, Dunbar L, et al. Guided care for multimorbid older adults. Gerontologist. 2007; 47:697-704.
PubMed
CrossRef
 
Zuckerman B, Parker S, Kaplan-Sanoff M, Augustyn M, Barth MC. Healthy Steps: a case study of innovation in pediatric practice. Pediatrics. 2004; 114:820-6.
PubMed
 
Toseland RW, O'Donnell JC, Engelhardt JB, Richie J, Jue D, Banks SM. Outpatient geriatric evaluation and management: is there an investment effect? Gerontologist. 1997; 37:324-32.
PubMed
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Solberg LI, Asche SE, Fontaine P, Flottemesch TJ, Anderson LH. Trends in quality during medical home transformation. Ann Fam Med. 2011; 9:515-521.
PubMed
CrossRef
 
Domino ME, Humble C, Lawrence WW Jr, Wegner S. Enhancing the medical homes model for children with asthma. Med Care. 2009; 47:1113-20.
PubMed
CrossRef
 
Wise CG, Bahl V, Mitchell R, West BT, Carli T. Population-based medical and disease management: an evaluation of cost and quality. Dis Manag. 2006; 9:45-55.
PubMed
CrossRef
 
Schraeder C, Dworak D, Stoll JF, Kucera C, Waldschmidt V, Dworak MP. Managing elders with comorbidities. J Ambul Care Manage. 2005; 28:201-9.
PubMed
 
Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting population-based care into practice: real option or rhetoric? J Am Board Fam Pract. 1998; 11:116-26.
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Rula EY, Pope JE, Stone RE. A review of healthways' medicare health support program and final results for two cohorts. Population Health Management. 2011; 14:S-3-s-10.
 
Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med. 2000; 160:1825-33.
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Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM. The effect of technology-supported, multidisease care management on the mortality and hospitalization of seniors. J Am Geriatr Soc. 2008; 56:2195-202.
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Steele GD, Haynes JA, Davis DE, Tomcavage J, Stewart WF, Graf TR, et al. How Geisinger's advanced medical home model argues the case for rapid-cycle innovation. Health Aff (Millwood). 2010; 29:2047-53.
PubMed
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Martin AB, Crawford S, Probst JC, Smith G, Saunders RP, Watkins KW, et al. Medical homes for children with special health care needs: a program evaluation. J Health Care Poor Underserved. 2007; 18:916-30.
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Rubin CD, Sizemore MT, Loftis PA, Adams-Huet B, Anderson RJ. The effect of geriatric evaluation and management on Medicare reimbursement in a large public hospital: a randomized clinical trial. J Am Geriatr Soc. 1992; 40:989-95.
PubMed
 
Reid RJ, Coleman K, Johnson EA, Fishman PA, Hsu C, Soman MP, et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010; 29:835-43.
PubMed
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Gilfillan RJ, Tomcavage J, Rosenthal MB, Davis DE, Graham J, Roy JA, et al. Value and the medical home: effects of transformed primary care. Am J Manag Care. 2010; 16:607-14.
PubMed
 
Peikes D, Chen A, Schore J, Brown R. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA. 2009; 301:603-18.
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Maeng DD, Graham J, Graf TR, Liberman JN, Dermes NB, Tomcavage J, et al. Reducing long-term cost by transforming primary care: evidence from Geisinger's medical home model. Am J Manag Care. 2012; 18:149-55.
PubMed
 
Institute of Medicine Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Pr; 2001.
 
Berwick DM. Making good on ACOs' promise—the final rule for the Medicare shared savings program. N Engl J Med. 2011; 365:1753-6.
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Sommers BD, Bindman AB. New physicians, the Affordable Care Act, and the changing practice of medicine. JAMA. 2012; 307:1697-8.
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Boyd CM, Shadmi E, Conwell LJ, Griswold M, Leff B, Brager R, et al. A pilot test of the effect of guided care on the quality of primary care experiences for multimorbid older adults. J Gen Intern Med. 2008; 23:536-42.
PubMed
CrossRef
 
Boult C, Reider L, Leff B, Frick KD, Boyd CM, Wolff JL, et al. The effect of guided care teams on the use of health services: results from a cluster-randomized controlled trial. Arch Intern Med. 2011; 171:460-6.
PubMed
CrossRef
 
Toseland RW, O'Donnell JC, Engelhardt JB, Hendler SA, Richie JT, Jue D. Outpatient geriatric evaluation and management. Results of a randomized trial. Med Care. 1996; 34:624-40.
PubMed
CrossRef
 
Minkovitz CS, Hughart N, Strobino D, Scharfstein D, Grason H, Hou W, et al. A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children Program. JAMA. 2003; 290:3081-91.
PubMed
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Crabtree BF, Nutting PA, Miller WL, Stange KC, Stewart EE, Jaen CR. Summary of the National Demonstration Project and recommendations for the patient-centered medical home. Ann Fam Med. 2010; 8:Suppl 1S80-90; S92.
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Miller WL, Crabtree BF, Nutting PA, Stange KC, Jaen CR. Primary care practice development: a relationship-centered approach. Ann Fam Med. 2010; 8:Suppl 1S68-79; S92.
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Jaen CR, Ferrer RL, Miller WL, Palmer RF, Wood R, Davila M, et al. Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project. Ann Fam Med. 2010; 8:Suppl 1S57-67; S92.
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Stewart EE, Nutting PA, Crabtree BF, Stange KC, Miller WL, Jaen CR. Implementing the patient-centered medical home: observation and description of the national demonstration project. Ann Fam Med. 2010; 8:Suppl 1S21-32; S92.
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Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009; 7:254-60.
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Leff B, Reider L, Frick KD, Scharfstein DO, Boyd CM, Frey K, et al. Guided care and the cost of complex healthcare: a preliminary report. Am J Manag Care. 2009; 15:555-9.
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Marsteller JA, Hsu YJ, Reider L, Frey K, Wolff J, Boyd C, et al. Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care. Ann Fam Med. 2010; 8:308-15.
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Boyd CM, Reider L, Frey K, Scharfstein D, Leff B, Wolff J, et al. The effects of guided care on the perceived quality of health care for multi-morbid older persons: 18-month outcomes from a cluster-randomized controlled trial. J Gen Intern Med. 2010; 25:235-42.
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Wolff JL, Giovannetti ER, Boyd CM, Reider L, Palmer S, Scharfstein D, et al. Effects of guided care on family caregivers. Gerontologist. 2010; 50:459-70.
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Wolff JL, Rand-Giovannetti E, Palmer S, Wegener S, Reider L, Frey K, et al. Caregiving and chronic care: the guided care program for families and friends. J Gerontol A Biol Sci Med Sci. 2009; 64:785-91.
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Minkovitz CS, Strobino D, Mistry KB, Scharfstein DO, Grason H, Hou W, et al. Healthy Steps for Young Children: sustained results at 5.5 years. Pediatrics. 2007; 120:658-68.
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CrossRef
 
Coleman K, Reid RJ, Johnson E, Hsu C, Ross TR, Fishman P, et al. Implications of reassigning patients for the medical home: a case study. Ann Fam Med. 2010; 8:493-8.
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Fishman PA K, Johnson EA, Coleman K, Larson EB, Hsu C, Ross TR, et al. Impact on seniors of the patient-centered medical home: evidence from a pilot study. Gerontologist. 2012.
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Sylvia ML, Griswold M, Dunbar L, Boyd CM, Park M, Boult C. Guided care: cost and utilization outcomes in a pilot study. Dis Manag. 2008; 11:29-36.
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Dorr DA, Wilcox A, Burns L, Brunker CP, Narus SP, Clayton PD. Implementing a multidisease chronic care model in primary care using people and technology. Dis Manag. 2006; 9:1-15.
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Farmer JE, Clark MJ, Sherman A, Marien WE, Selva TJ. Comprehensive primary care for children with special health care needs in rural areas. Pediatrics. 2005; 116:649-56.
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Lee JG, Dayal G, Fontaine D. Starting a medical home: better health at lower cost. Healthc Financ Manage. 2011; 65:70-6, 78, 80.
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Palfrey JS, Sofis LA, Davidson EJ, Liu J, Freeman L, Ganz ML. The Pediatric Alliance for Coordinated Care: evaluation of a medical home model. Pediatrics. 2004; 113:1507-16.
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Samuels RC, Liu J, Sofis LA, Palfrey JS. Immunizations in children with special health care needs in a medical home model of care. Matern Child Health J. 2008; 12:357-62.
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Rankin KM, Cooper A, Sanabria K, Binns HJ, Onufer C. Illinois medical home project: pilot intervention and evaluation. Am J Med Qual. 2009; 24:302-9.
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Treadwell J, Bean G, Warner W. Supporting disease management through intervention in the medical home. Prof Case Manag. 2009; 14:192-7.
PubMed
 
Chandler C, Barriuso P, Rozenberg-Ben-Dror K, Schmitt B. Pharmacists on a primary care team at a Veterans Affairs medical center. Am J Health Syst Pharm. 1997; 54:1280-7.
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Farris KB, Cote I, Feeny D, Johnson JA, Tsuyuki RT, Brilliant S, et al. Enhancing primary care for complex patients. Demonstration project using multidisciplinary teams. Can Fam Physician. 2004; 50:998-1003.
PubMed
 
Peleg R, Press Y, Asher M, Pugachev T, Glicensztain H, Lederman M, et al. An intervention program to reduce the number of hospitalizations of elderly patients in a primary care clinic. BMC Health Serv Res. 2008; 8:36.
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Schifalacqua M, Hook M, O'Hearn P, Schmidt M. Coordinating the care of the chronically ill in a world of managed care. Nurs Adm Q. 2000; 24:12-20.
PubMed
 
Vedel I, De Stampa M, Bergman H, Ankri J, Cassou B, Mauriat C, et al. A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly. Aging Clin Exp Res. 2009; 21:414-23.
PubMed
 
Waxmonsky JA, Giese AA, McGinnis GF, Reynolds RT, Abrahamson A, McKitterick ML, et al. Colorado access' enhanced care management for high-cost, high-need Medicaid members: preliminary outcomes and lessons learned. J Ambul Care Manage. 2011; 34:183-91.
PubMed
 

Figures

Grahic Jump Location
Figure 1.

Definition of the patient-centered medical home.

Based on the Agency for Healthcare Research and Quality's definition (8). Includes each of categories 1 through 4.

Grahic Jump Location
Grahic Jump Location
Figure 2.

Summary of evidence search and selection.

CINAHL = Cumulative Index to Nursing & Allied Health Literature; PCMH = patient-centered medical home.

* All studies/articles included for effectiveness studies were also included in the analysis of PCMH intervention descriptions.

Grahic Jump Location
Grahic Jump Location
Figure 3.

PCMH take-home points.

PCMH = patient-centered medical home.

Grahic Jump Location

Tables

Table Jump PlaceholderAppendix Table 1. 

Characteristics of Included Studies—Comparative Randomized, Controlled Trials (Questions 1–3)

Table Jump PlaceholderAppendix Table 2. 

Characteristics of Included Studies—Comparative Observational Studies (Questions 1–3)

Table Jump PlaceholderAppendix Table 3. 

Characteristics of Included Studies—Noncomparative Studies (Questions 2 and 3)

Table Jump PlaceholderAppendix Table 4. 

PCMH Components Implemented and Implementation Strategies Used (Questions 2 and 3)

Table Jump PlaceholderAppendix Table 5. 

Meta-analyses for Inpatient and Emergency Department Utilization Reported in Randomized, Controlled Trials

Table Jump PlaceholderTable 1. 

Comparative Study Characteristics and Reported Outcomes

Table Jump PlaceholderTable 2. 

Summary of the Strength of Evidence for Effects of PCMH

Table Jump PlaceholderAppendix Table 6. 

Reported Outcomes by Study

References

Martin A, Lassman D, Whittle L, Catlin A, National Health Expenditure Accounts Team. Recession contributes to slowest annual rate of increase in health spending in five decades. Health Aff (Millwood). 2011; 30:11-22.
PubMed
CrossRef
 
McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003; 348:2635-45.
PubMed
CrossRef
 
Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998–1999 to 2000–2001. JAMA. 2003; 289:305-12.
PubMed
CrossRef
 
Saaddine JB, Cadwell B, Gregg EW, Engelgau MM, Vinicor F, Imperatore G, et al. Improvements in diabetes processes of care and intermediate outcomes: United States, 1988–2002. Ann Intern Med. 2006; 144:465-74.
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CrossRef
 
Grant RW, Buse JB, Meigs JB. Quality of diabetes care in U.S. academic medical centers: low rates of medical regimen change. Diabetes Care. 2005; 28:337-442.
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