Table 1.

PCMH Function and Forms Matrix

Patient-Centered Medical Home (PCMH) principles 1–5
Motivating need/problem	Core functions (standardized)	Forms (tailored)
1. Accessible care
Unreliable patient access to health care when needed	A. Offer enhanced options for access to in-person care	I. Examples: • In-person care outside of traditional business hours 31– 33 • Schedule same day appointments 33, 34
	B. Facilitate and document remote access to health consultation/clinical advice	II. Examples: • 24/7 patient access to clinical advice 31, 35 • 24/7 on-call patient access to PCMH team 33
	C. Create written process and defined standards to facilitate patient access to their EHR	III. Examples: • Online patient portals 32, 36 • Secure electronic messaging 37
2. Coordinated care
Lack of communication and coordination across health care providers and institutions	A. Create an infrastructure to exchange information via shared records	IV. Examples: • Electronic health records to access, document, and share patient data 38 • Tracking mechanisms to ensure notification of patient encounters and creation of appropriate transition plans 36, 39
	B. Provide guidance to patients to navigate and cooperate within a team-based care approach	V. Examples: • Tracking and follow-up for all tests and results, with identified time frames for notifying patients of results 36, 39 • Regular case review meetings with interdisciplinary team 40
	C. Create explicit workforce agreements regarding division of labor	VI. Examples: • Dedicated care manager who is responsible for overall management of patient’s care plan 40 • Clear process for providing care management services 34
3. Committed to quality care
Care is not consistently driven by scientific evidence and supported by clinical information systems	A. Deliver care guided by evidence-based principles	VII. Examples: • Documented clinic-wide improvement strategy with performance goals (derived from patient/family, and other team members feedback), publicly reported measures, and areas for clinical and operational improvement 31
	B. Enable a system for decision support and education to facilitate use of evidence	VIII. Examples: • Electronic prescribing 32, 35, 36, 38 • Evidence-based clinical decision-making tools 40
	C. Track population health status and create mechanisms to encourage/achieve health promotion and prevention	IX. Examples: • Registry and risk stratification tools to assess health status and needs of the entire practice 38 • Performance reports to track and compare results for the established population of patients in the practice 36, 39
	D. Monitor and measure care as delivered to assure adherence to evidence-based standards	X. Examples: • Health home provider makes use of available HIT and accesses data through the regional health information organization/qualified entity 41
4. Comprehensive care
Care is episodic. Lack of innovative models of team work to support team-based care	A. Identify needs and services in health continuum, including social and behavioral needs	XI. Examples: • Care plans that are longitudinal and meet patients’ complex healthcare needs 38 • Care plans that include community-based and other social support services 40
	B. Establish sources of services and arrangements to deliver and document service delivery	XII. Examples: • Policies and procedures to support effective collaborations with community-based resources 40 • Screening strategy for mental health, substance use, and developmental conditions with documentation of onsite and local referral resources 31
5. Patient-centered care
Care is often inconsistent with, and not planned or carried out in consideration of, patient preferences and values. Lack of physician-patient relationship that is based on mutual responsibility and trust.	A. Assess patient values, needs and preferences	XIII. Examples: • Written materials published in primary language(s) of the community 33 • Providers or telephonic trained interpreters speak a patient and family’s language of choice 31
	B. Take patient values and preferences into account to design and deliver care	XIV. Examples: • Care plan identifies family members and other supports involved in the patient’s care 40 • PCMH-related communication tools 36, 39
	C. Foster a relationship-based care (vs. impersonal) with an orientation to whole person care	XV. Examples: • Patient-centered care planning to engage patients in their care 33 • Peer supports, support groups, and self-care programs to engage patients in their care 40
	D. Educate and support patients in learning to manage their own care and fully participate in care decisions	XVI. Examples: • Strategies for patient/family’s participation in a health care decision using informed and shared decision-making 38 • Individualized care plan for patients includes complex medical and social concerns 31