Table 2.

PCMH demonstrations reporting outcomes in diabetes care

PCMH demonstration	Start	Size	Improvements	Key transformation features
Community Care of North Carolina	1998	1,200 practices; 3,000 physicians	Improvements in A1C, blood pressure, and LDL cholesterol control (29); all three measures were above the NCQA target benchmarks. Reductions in emergency room and inpatient admissions; reductions in outpatient and pharmacy utilization (29)	Care coordination assisted by care managers; (Medicaid) – Single payer; PMPM fee; regular reporting of quality measures; community health networks
Geisinger Health System	2006	25 outpatient practice sites; 110 physicians	Improvements in the diabetic bundle (9 evidence-based quality indicators of diabetes care) (19). Reduction in inpatient admissions and total medical costs (33)	Care coordination assisted by care managers; single payer; monthly payments per physician; monthly infrastructure payments; performance-tied bonus payments; regular reporting of quality measures; patient registry; patient access to EHR
Pennsylvania Chronic Care Initiative	2008	102 practices; 518 physicians	Improvements in A1C, blood pressure, and LDL cholesterol control in the first year (35)	Care coordination assisted by care managers; multipayer; infrastructure payments based on NCQA certification; regular reporting of quality measures; patient registry; practice coaches; learning collaborative
Rhode Island Chronic Care Sustainability Initiative	2008	13 practices; 53 physicians	Improvements in A1C documentation, blood pressure control, and smoking advice documentation 6 months after begin of the initiative (36)	Care coordination assisted by care managers; multipayer; PMPM fee; care management reimbursement; regular reporting of quality measures; patient registry; practice coaches; learning collaborative
Group Health Cooperative Medical Home Pilot	2007	1 Seattle clinic serving 9,200 adult patients	Improvement in the composite quality score in the first and second year (38). Improved patient satisfaction; reductions in emergency room and inpatient admissions; return of $1.5 for every dollar invested in the PCMH after 21 months (38)	Care coordination assisted by care managers; single payer; no reimbursement change; reduction of physician panel size; regular reporting of quality measures; patient registry; daily care team huddles to plan day, address problems and root cause analysis
Health Partners Medical Group, Minneapolis	2002	600 physicians; 50 clinics	Improvements in A1C, blood pressure, LDL cholesterol, aspirin use and tobacco cessation (40). Reductions in inpatient admissions and readmissions; clinic cost savings (40)	Care coordination assisted by care managers; single payer; change from salary to productivity based physician payments; regular reporting of quality measures; patient registry; learning collaborative
Colorado PCMH Pilot	2009	17 practices	Improvements in A1C, LDL cholesterol and blood pressure control (42); all measures above NCQA quality benchmarks including tobacco cessation and depression screening. Reductions in emergency room and inpatient admissions; improved patient satisfaction; improved healthcare worker satisfaction (42)	Care coordination assisted by care managers; multiple payer; PMPM fee; pay-for-performance payments; regular reporting of quality measures; patient registries; practice coaches; learning collaborative
The PCMH National Demonstration Project	2006	36 practices	Improvements in chronic illness care quality (44). No improvements in patient experience; practice coaches helpful in adopting more Medical Home features (44)	Care coordination; regular reporting of quality measures; patient registry; improved access; practice coaches; learning collaborative

PMPM, per-member-per-month.