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Medical homes

Health Factors: Access to Care Quality of Care
Decision Makers: State Government Grantmakers Healthcare Professionals & Advocates
Evidence Rating: Scientifically Supported
Population Reach: 100% of WI's population
Impact on Disparities: Likely to decrease disparities

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Medical homes provide continuous, comprehensive, whole person primary care (NCQA-PCMH, AHRQ-PCMH). In this model of care, personal physicians and their teams coordinate care across the health care system, working with patients to address all their preventive, acute, and chronic health care needs, and arranging care with other qualified health professionals as needed. Medical homes offer enhanced access, including expanded hours and easy communication options for patients. They also practice evidence-based medicine, measure performance, and strive to improve care quality (AHRQ-PCMH).

Expected Beneficial Outcomes

Improved quality of care
Increased access to care
Increased continuity of care
Increased patient engagement
Increased practice of evidence-based medicine
Increased preventive care
Improved care for chronic conditions
Reduced hospital utilization
Increased patient satisfaction

Evidence of Effectiveness

There is strong evidence that medical homes improve health care quality and access to care compared to traditional care (Rosenthal 2008, Homer 2008, van Walraven 2010, Alexander 2012, Hoff 2013). Additional evidence is needed to determine which components of medical homes yield strongest effects (AHRQ-PCMH Resources).

Medical homes increase continuity of care (van Walraven 2010), use of evidence-based medicine (Homer 2008), and patient or family participation in care (Rosenthal 2008, Homer 2008). They also increase preventive care (Alexander 2012) and screening, and improve chronic disease management (Hoff 2013). By proactively monitoring and caring for patients, medical homes can reduce preventable emergency room visits (van Walraven 2010, Hoff 2013) and hospitalizations (Hoff 2013, van Walraven 2010, Alexander 2012).

Medical homes appear to increase patient satisfaction (Alexander 2012, van Walraven 2010), and can reduce provider burnout (Hoff 2013). In some circumstances, medical homes may allow patients to access care more quickly and easily than traditional care models (Homer 2008, Christensen 2013, Kern 2013) and may reduce their unmet medical needs (Strickland 2011, O'Malley 2012, Bennedict 2008).

Effects appear strongest for children with special health care needs (Homer 2008) and persons with chronic conditions such as diabetes or mental health needs (Amiel 2011). Medical homes can also reduce emergency visits for asthmatics (Chin 2009, Diedhiou 2010).

Research on primary care transformation indicates that practices becoming medical homes should first build a relationship-centered workplace with shared leadership and time for group planning. Then, rather than incremental change or following top-down directives, practices should pursue group-directed, whole-system transformation (Crabtree 2011, Nutting 2009). Practices should also help doctors develop the skills for team-based care, and expect a change process up to three years long (Nutting 2009). Survey results suggest that joining learning collaboratives (McMullen 2013) and hiring care coordinators (McAllister 2013) may help ease the transformation process.

Medical homes can yield cost savings over traditional care in some circumstances (Homer 2008, Rosenthal 2008), but not in others (Hoff 2013). Most state medical home initiatives have been associated with increased quality and reduced costs (Takach 2011).


United States

As of 2012, about half of all states had enacted changes to increase medical home access for Medicaid recipients. States are using a variety of financial incentives to encourage practices to become medical homes. Twenty-one states are aligning pay with quality standards, and 14 offer providers performance-based pay incentives (Takach 2012).

In 2010, the Veterans Health Administration transitioned its primary care clinics to a patient-centered medical home model (Hebert 2014). 

The Affordable Care Act (ACA) includes some Medicare and Medicaid payment reforms consistent with the medical home model (SNMHI-ACA), and a medical home demonstration project involving up to 195,000 Medicare patients (CMS-ACA).


Wisconsin received a federal demonstration grant to coordinate health care across sectors for individuals eligible for both Medicare and Medicaid. Currently, state AIDS Service Organizations meeting national or state medical home standards are paid monthly case management fees (NASHP-MH WI). 

Implementation Resources

AHRQ-PCMH Resources - Agency for Healthcare Research and Quality (AHRQ). Patient centered medical home (PCMH) resource center. Accessed on February 10, 2016
CWF-MH - The Commonwealth Fund (CWF). Becoming a medical home: Implementation guides. Accessed on February 1, 2016
NCMHI - National Center for Medical Home Implementation. Accessed on March 3, 2016
NCQA-PCMH - National Committee for Quality Assurance (NCQA). PCMH eligibility. Accessed on May 24, 2016
SNMHI - Safety Net Medical Home Initiative (SNMHI). Patient-centered medical home resources and tools. Accessed on January 27, 2016

Citations - Description

AHRQ-PCMH - Agency for Healthcare Research and Quality (AHRQ). Patient centered medical home (PCMH). Accessed on November 30, 2015
NCQA-PCMH - National Committee for Quality Assurance (NCQA). PCMH eligibility. Accessed on May 24, 2016

Citations - Evidence

AHRQ-PCMH Resources - Agency for Healthcare Research and Quality (AHRQ). Patient centered medical home (PCMH) resource center. Accessed on February 10, 2016
Alexander 2012 - Alexander JA, Bae D. Does the patient-centred medical home work? A critical synthesis of research on patient-centred medical homes and patient-related outcomes. Health Services Management Research. 2012;25(2):51–9. Accessed on November 25, 2015
Amiel 2011* - Amiel JM, Pincus HA. The medical home model: New opportunities for psychiatric services in the United States. Current Opinion in Psychiatry. 2011;24(6):562-8. Accessed on November 24, 2015
Bennedict 2008 - Benedict RE. Quality medical homes: Meeting children’s needs for therapeutic and supportive services. Pediatrics. 2008;121(1):e127-34. Accessed on November 27, 2015
Chin 2009 - Chin MH, Alexander-Young M, Burnet DL. Health care quality-improvement approaches to reducing child health disparities. Pediatrics. 2009;124(Suppl 3):S224-36. Accessed on December 1, 2015
Christensen 2013* - Christensen EW, Dorrance KA, Ramchandani S, et al. Impact of a patient-centered medical home on access, quality, and cost. Military Medicine. 2013;178(2):135–41. Accessed on November 23, 2015
Crabtree 2011* - Crabtree BF, Nutting PA, Miller WL, et al. Primary care practice transformation is hard work: Insights from a 15-year developmental program of research. Medical Care. 2011;49(12 Suppl 1):S28-35. Accessed on December 8, 2015
Diedhiou 2010* - Diedhiou A, Probst JC, Hardin JW, Martin AB, Xirasagar S. Relationship between presence of a reported medical home and emergency department use among children with asthma. Medical Care Research and Review. 2010;67(4):450-75. Accessed on January 20, 2016
Hoff 2013* - Hoff T, Weller W, DePuccio M. The patient-centered medical home: A review of recent research. Medical Care Research and Review. 2012;69(6):619–44. Accessed on February 17, 2016
Homer 2008 - Homer CJ, Klatka K, Romm D, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics. 2008;122(4):e922-37. Accessed on February 5, 2016
Kern 2013 - Kern LM, Dhopeshwarkar R V, Edwards A, Kaushal R. Patient experience over time in patient-centered medical homes. American Journal of Managed Care. 2013;19(5):403–10. Accessed on February 5, 2016
McAllister 2013 - McAllister JW, Cooley WC, Van Cleave J, Boudreau AA, Kuhlthau K. Medical home transformation in pediatric primary care - What drives change? Annals Of Family Medicine. 2013;11(S1):S90–8. Accessed on March 14, 2016
McMullen 2013 - Mcmullen CK, Schneider J, Firemark A, Davis J, Spofford M. Cultivating engaged leadership through a learning collaborative: Lessons from primary care renewal in Oregon safety net clinics. Annals of Family Medicine. 2013;11(Suppl 1):S34–40. Accessed on March 1, 2016
Nutting 2009 - Nutting PA, Miller WL, Crabtree BF, et al. Initial lessons from the First National Demonstration Project on practice transformation to a patient-centered medical home. Annals of Family Medicine. 2009;7(3):254-60. Accessed on May 24, 2016
O'Malley 2012* - O’Malley AS. After-hours access to primary care practices linked with lower emergency department use and less unmet medical need. Health Affairs. 2013;32(1):175–83. Accessed on March 2, 2016
Rosenthal 2008 - Rosenthal TC. The medical home: Growing evidence to support a new approach to primary care. Journal of the American Board of Family Medicine. 2008;21(5):427-40. Accessed on May 24, 2016
Strickland 2011 - Strickland BB, Jones JR, Ghandour RM, Kogan MD, Newacheck PW. The medical home: Health care access and impact for children and youth in the United States. Pediatrics. 2011;127(4):604–11. Accessed on November 9, 2015
Takach 2011* - Takach M. Reinventing medicaid: State innovations to qualify and pay for patient-centered medical homes show promising results. Health Affairs. 2011;30(7):1325-34. Accessed on May 24, 2016
van Walraven 2010* - van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: A systematic and critical review. Journal of Evaluation in Clinical Practice. 2010;16(5):947-56. Accessed on November 10, 2015

Citations - Implementation

CMS-ACA - Centers for Medicare & Medicaid Services (CMS). New Affordable Care Act (ACA) support to improve care coordination for nearly 200,000 people with Medicare. US Department of Health and Human Services (US DHHS). Accessed on March 13, 2017
Hebert 2014* - Hebert P, Liu C, Wong E, et al. Patient-centered medical home initiative produced modest economic results for Veterans Health Administration, 2010–12. Health Affairs. 2014;33(6):980-987. Accessed on January 28, 2016
NASHP-MH WI - National Academy for State Health Policy (NASHP). Wisconsin. Accessed on March 3, 2016
SNMHI-ACA - Safety Net Medical Home Initiative (SNMHI). Health reform and the patient-centered medical home: Policy provisions and expectations of the patient protection and affordable care act. Accessed on February 1, 2016
Takach 2012* - Takach M. About half of the states are implementing patient-centered medical homes for their medicaid populations. Health Affairs. 2012;31(11):2432–40. Accessed on November 9, 2015

Page Last Updated

September 4, 2014

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