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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, primary care providers 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 preventive care
Reduced emergency room visits
Reduced hospital utilization
Increased continuity of care
Increased patient engagement
Increased practice of evidence-based medicine
Improved care for chronic conditions
Increased patient satisfaction

Evidence of Effectiveness

There is strong evidence that medical homes improve quality of health care and access to care (van den Berk-Clark 2017, Olayiwola 2017, Alexander 2012, van Walraven 2010, Rosenthal 2008, Homer 2008, Hoff 2013), and increase the use of preventive services compared to traditional care (Sinaiko 2017, Olayiwola 2017, Hadland 2014, Jackson 2013, Alexander 2012). Medical homes reduce preventable emergency room visits (van den Berk-Clark 2017, Hadland 2014, van Walraven 2010, Chin 2009, Diedhiou 2010, Hoff 2013) and hospitalizations (van den Berk-Clark 2017, Alexander 2012, van Walraven 2010, Hoff 2013).

Medical homes increase continuity of care (van Walraven 2010), use of evidence-based medicine (Homer 2008), and patient and family participation in care (Rosenthal 2008, Homer 2008). Medical homes improve adherence to treatment (van den Berk-Clark 2017), increase general preventive screenings such as cholesterol and blood pressure checks (Hoff 2013), increase screening for cervical cancer and breast cancer, and reduce specialist visits (Sinaiko 2017).

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 unmet medical needs (Strickland 2011, O'Malley 2012, Bennedict 2008).

Effects appear strongest for children with special health care needs (Homer 2008) and individuals with chronic conditions such as diabetes or mental illness (Amiel 2011). Medical homes improve chronic disease management (Hoff 2013), including diabetes care (van den Berk-Clark 2017).  Medical homes can also reduce emergency visits for asthmatic individuals (Chin 2009, Diedhiou 2010), Latinos and Vietnamese with mental illness (Olayiwola 2017), and children insured by Medicaid (Christensen 2015). Healthy children with medical homes are more likely to receive preventive care and developmental screenings, experience a greater health-related quality of life, and are less likely to seek care at the emergency department than children who receive traditional care (Hadland 2014).

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, Jackson 2013). Most state medical home initiatives have been associated with increased quality and reduced costs (Takach 2011).

Medical homes have been shown to improve health disparities related to race, income, gender, and age (Olayiwola 2017).


United States

As of 2018, 26 states have enacted changes to increase medical home access for Medicaid recipients (NASHP-Map). The National Committee for Quality Assurance’s (NCQA’s) Patient-Centered Medical Home Recognition Program is the most widely used medical home evaluation program in the nation; it has recognized over 12,000 practices with 60,000 clinicians for their commitment to a patient-centered approach to care and quality improvement (NCQA-PCMH). The New York State Department of Health (NYSDOH) collaborated with NCQA to develop the New York State customized PCMH Recognition Program in support of New York’s dedication to the medical home model (NCQA-NYS PCHM). The Veterans Health Administration has utilized a patient-centered medical home model known as Patient Aligned Care Teams (PACT) since 2010 (Hebert 2014, VA-PACT).


The Wisconsin Medical Home Initiative promotes children’s health and development by supporting medical home implementations, primary care clinicians, and families (WiSMHI).

Implementation Resources

AHRQ-PCMH Resources - Agency for Healthcare Research and Quality (AHRQ). Patient centered medical home (PCMH) resource center. Accessed on April 23, 2018
CWF-MH - The Commonwealth Fund (CWF). Becoming a medical home: Implementation guides. Accessed on April 23, 2018
NCMHI - National Center for Medical Home Implementation. Accessed on April 23, 2018
NCQA-PCMH eligibility - National Committee for Quality Assurance (NCQA). PCMH eligibility. Accessed on May 11, 2018
PCPCC-PCMH map - Patient-Centered Primary Care Collaborative (PCPCC). Primary care innovations and patient-centered medical home (PCMH) map by state. Accessed on May 16, 2018
SNMHI - Safety Net Medical Home Initiative (SNMHI). Patient-centered medical home resources and tools. Accessed on April 23, 2018

Citations - Description

AHRQ-PCMH - Agency for Healthcare Research and Quality (AHRQ). Patient centered medical home (PCMH). Accessed on April 23, 2018
NCQA-PCMH - National Committee for Quality Assurance (NCQA). Patient-Centered Medical Home (PCMH) Recognition Program. Accessed on May 16, 2018

Citations - Evidence

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 April 23, 2018
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 April 23, 2018
Bennedict 2008 - Benedict RE. Quality medical homes: Meeting children’s needs for therapeutic and supportive services. Pediatrics. 2008;121(1):e127-34. Accessed on April 23, 2018
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 April 23, 2018
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 April 23, 2018
Christensen 2015* - Christensen AL, Zickafoose JS, Natzke B, McMorrow S, Ireys HT. Associations between practice-reported medical homeness and health care utilization among publicly insured children. Academic Pediatrics. 2015;15(3):267-274. Accessed on May 16, 2018
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 April 23, 2018
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 April 23, 2018
Hadland 2014 - Hadland SE, Long WE. A systematic review of the medical home for children without special health care needs. Maternal and Child Health Journal. 2014;18(4):891-898. Accessed on May 16, 2018
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 April 23, 2018
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 April 23, 2018
Jackson 2013 - Jackson GL, Powers BJ, Chatterjee R, et al. The patient-centered medical home: A systematic review. Annals of Internal Medicine. 2013;158(3):169-178. Accessed on May 16, 2018
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 April 23, 2018
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 April 23, 2018
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 April 23, 2018
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 April 23, 2018
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 April 23, 2018
Olayiwola 2017 - Olayiwola JN, Sheth S, Mleczko V, Choi AL, Sharma AE. The impact of the patient-centered medical home on health disparities in adults: A systematic review of the evidence. Journal of Health Disparities Research and Practice. 2017;10(1):68-96. Accessed on May 16, 2018
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 April 23, 2018
Sinaiko 2017 - Sinaiko AD, Landrum MB, Meyers DJ, et al. Synthesis of research on patient-centered medical homes brings systematic differences into relief. Health Affairs. 2017;36(3):500-508. Accessed on May 16, 2018
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 April 23, 2018
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 April 23, 2018
van den Berk-Clark 2017* - van den Berk-Clark C, Doucette E, Rottnek F, et al. Do patient-centered medical homes improve health behaviors, outcomes, and experiences of low-income patients? A systematic review and meta-analysis. Health Services Research. 2017:1-22. Accessed on May 16, 2018
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 April 23, 2018

Citations - Implementation

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 May 11, 2018
NASHP-Map - National Academy for State Health Policy (NASHP). State delivery system and payment reform map. Accessed on May 16, 2018
NCQA-NYS PCHM - National Committee for Quality Assurance (NCQA). New York State Patient-Centered Medical Home (NYS PCMH) Recognition Program. Accessed on May 16, 2018
NCQA-PCMH - National Committee for Quality Assurance (NCQA). Patient-Centered Medical Home (PCMH) Recognition Program. Accessed on May 16, 2018
VA-PACT - US Department of Veterans Affairs (VA). Patient Aligned Care Team (PACT). Accessed on May 16, 2018
WiSMHI - Wisconsin Medical Home Initiative (WiSMHI). An initiative of Children's Health Alliance of Wisconsin. Accessed on May 16, 2018

Page Last Updated

May 16, 2018

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