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
- 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: Oral Health Integration
- Oral Health Integration Executive Summary
- Oral Health Integration Implementation Guide
- Expanding Oral Health Access for Children: Early Experience from the Bluegrass Community Health Center
- Interprofessional Education and Care at the New York University Nursing Faculty Practice
- Integrating Oral Health into Primary Care: Lessons Learned from Rodgers Health
- Sound Family Medicine Integrates Oral Health into Primary Care for Adults with Diabetes
- Implementation of the Oral Health Delivery Framework at Dimock Community Health Center
- Case Examples: Electronic Health Record Use in Oral Health Integration
- Case Examples: Oral Health Integration Referral Experiences
- The Case for Change: Incorporating Oral Health in Routine Medical Care
- Summary of Patient Education Resources
- Rapid Oral Health Screening and Risk Assessment
- Summary of Primary Care Clinical Interventions
- Recommended Oral Health Screening Questions
- Primary Care Management of Oral Health in Pregnancy
- Oral Health and Pregnancy Case Studies
- Primary Care Management of Oral Health in Patients with Diabetes
- Oral Health and Diabetes Case Studies
- Primary Care Management of Oral Health in Children and Adolescents
- Oral Health and Pediatrics Case Studies
- Oral Health Information Technology Assessment
- Oral Health Practice Readiness Assessment
- Sample Oral Health Integration Kickoff Meeting Agenda
- Oral Health Integration Workflow Optimization: A Streamlined Guide for Primary Care Practices
- Workflow Optimization for Oral Health Integration
- Referral Agreement Template
- Referral Template for Primary Care Referrals to Dentistry
- Sample Completed Referral for Primary Care Referrals to Dentistry
- Oral Health Referral Workflow Optimization
- Recommended Oral Health Integration Metrics
- Oral Health Data Reporting Template and Run Chart Tool
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
Special Topics
Our newest guide and tools will help you integrate preventive oral healthcare services into the primary care setting.
Contact Us
transformation@qualishealth.org