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All Resources

To help practices understand and implement the Patient-Centered Medical Home (PCMH) Model of Care, we created a library of resources and tools, all of which are publicly available. You can access these resources by following the links below. You can also download a registry of tools and resources, which includes all resources and tools hosted on the website and those hyperlinked within documents on the website.

Getting Started

Patient-Centered Medical Home Assessment (PCMH-A)
Introduction to the Safety Net Medical Home Initiative Implementation Guide Series
Change Concepts for Practice Transformation: Overview
Strategies and Tools to Orient and Engage Patients and Families to the Patient-Centered Medical Home Model of Care

Key Activities Checklist

Engaged Leadership

Engaged Leadership Executive Summary
Engaged Leadership: Strategies for Guiding PCMH Transformation
Engaged Leadership: How Health Center Board Members Can Support PCMH Transformation
PCMH Strategic Planning, Quality Improvement, and Business Processes Tool
Medical Home Digest: Engaged Leadership

Quality Improvement Strategy

Quality Improvement Strategy Executive Summary
Quality Improvement Strategy Part 1: Tools to Make and Measure Improvement
Quality Improvement Strategy Part 2: Optimizing Health Information Technology for Patient-Centered Medical Homes
A3 Type Report Template
Do It Yourself Run Chart
Cambridge Health Alliance Practice Improvement Team (PIT) Development Toolkit

Measurement Strategy Worksheet
Threshold Reference Table

Medical Home Digest: Quality Improvement/Enhanced Access


Empanelment Executive Summary
Empanelment: Establishing Patient-Provider Relationships
Patient Acuity Rubric
Determining the Right Panel Size
Addressing Staff Pushback for Empanelment
Sample PCP Assignment Policy
Scripting for Appointment Scheduling
Sample Provider Staffing and Scheduling Policy
Medical Home Digest: Empanelment

Continuous and Team-based Healing Relationships

Continuous and Team-Based Healing Relationships Executive Summary
Continuous and Team-Based Healing Relationships: Improving Patient Care Through Teams
Continuous and Team-Based Healing Relationships Supplement: Elevating the Role of the Medical/Clinical Assistant
Team-Based Planning Worksheet
Types of Call Study
Cambridge Health Alliance Model of Team-Based Care Implementation Guide and Toolkit
Medical Home Digest: Continuous and Team-Based Healing Relationships

Organized, Evidence-Based Care

Organized, Evidence-Based Care Executive Summary
Organized, Evidence-Based Care: Planning Care for Individual Patients and Whole Populations
Population Health: Patient Care Reminders Step-By-Step
Workflow Standardization Worksheet
Medical Home Digest: Organized, Evidence-Based Care

Organized, Evidence-Based Care: Behavioral Health Integration

Behavioral Health Integration Executive Summary
Behavioral Health Integration Implementation Guide
Making the Case for Change and Overcoming Resistance
GROW Pathway Planning Worksheet
GROW Pathway Planning Example
Common Barriers and Strategies to Support Effective Health Care Teams for Integrated Behavioral Health Tools
Resources to Support Behavioral Health Integration
Dorchester House Multi-Service Center Integrates Behavioral Health into Adult Primary Care
Tiburcio Vasquez Health Center Adapts to Integrate Behavioral Health with Primary Care
Integrating Behavioral Health into Primary Care: Lessons Learned from Central City Concern's Old Town Clinic
At CareSouth Carolina, Behavioral Health Care Meets the Health Needs of the "Whole Person"

Organized, Evidence-Based Care: The RN Care Manager

Organized, Evidence-Based Care: Improving Care for Complex Patients: The Role of the RN Care Manager

Patient-Centered Interactions

Patient-Centered Interactions Executive Summary
Patient-Centered Interactions: Engaging Patients in Health and Healthcare
Eliciting the Patient’s Perspective
The Patient-Centered Medical Home from the Patient’s Perspective
Patient Visit Sheet
Medical Home Digest: Patient-Centered Interactions

Enhanced Access

Enhanced Access Executive Summary
Enhanced Access: Providing the Care Patients Need, When They Need It
Guide to Appointment Confirmation Calls
Secret Shopper Exercise
Time to Third Next Available Appointment
Sample On-Call Guidelines
No-Show Management Guide
Standardized Switchboard Process Map
Building Better Care’s Open Access Management Implementation Toolkit

Care Coordination

Care Coordination Executive Summary
Care Coordination: Reducing Care Fragmentation in Primary Care
Medical Home Digest: Care Coordination

Coaching Guides

The Coach Medical Home website
Rapid Fire Session: Instruction Guide for Session Facilitators
Implementing the Patient-Centered Medical Home Model: A Practice Facilitator's Guide to Visiting Clinical Teams

Recognition and Payment

Change Concepts for Practice Transformation and 2014 NCQA PCMH™ Recognition Standards: A Crosswalk
Paying for the Medical Home Part 1: Payment Models to Support Patient-Centered Medical Home Transformation in the Safety Net
Paying for the Medical Home Part 2: Considering Social, Behavioral, and Environmental Factors in Payment Models
Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act

Peer Learning

2011 Summit Materials

Special Topics

Medical Home Digest: Lessons Learned
Medical Home Digest: Gathering Evidence
Medical Home Digest: Integrated Healthcare

Medical Home Digest: Vulnerable Populations
Medical Home Digest: Building Transformation Capacity

New Resources Now Available

"Oral Health: An Essential Component of Primary Care" presents a practical framework for delivering oral health preventive care as a component of routine medical care.

Visit the White Papers page to learn more.