Patient-Centered Medical Home Information and Resources

Patient-Centered Medical Home (PCMH) is a model of primary health care that many believe can improve health care in the U.S. by transforming how primary care is organized and delivered. The Health Resources and Services Administration (HRSA) supports and encourages all Section 330 funded health centers to become a recognized or accredited PCMH. CHAMPS has gathered the following information and resources to assist CHCs in understanding and becoming PCMHs. This webpage is designed to aid CHCs who are brand new to PCMH, those who have started the process of becoming a PCMH, and those who have already applied to become a recognized/accredited PCMH and require additional tools to successfully complete the process.

Please click or scroll down for:
Definition and Goals of PCMH
PCMH Recognition/Accreditation
First Steps in Becoming a Recognized/Accredited PCMH
Self Assessment Tools for Determining PCMH Readiness
Tools for Building a PCMH
Templates and Samples of PCMH Policy and Procedure
PCMH Demonstration Projects, Initiatives, and Pilot Projects
Education and Training on PCMH
Reports and Articles on PCMH
PCMH Consultation Services
Patient Satisfaction/Experience Surveys and Patient Activation/Engagement Resources


A Patient-Centered Medical Home (PCMH) is a model of primary health care that puts the patient at the center of health care. The definition of PCMH varies among the many agencies and organizations involved with PCMH development in the U.S. Following are definitions from three organizations.

American Academy of Family Physicians (AAFP)
A patient-center medical home integrates patients as active participants in their own health and well-being. Patients are cared for by a physician who leads the medical team that coordinates all aspects of preventive, acute, and chronic needs of patients using the best available evidence and appropriate technology. These relationships offer patients comfort, convenience, and optimal health throughout their lifetimes.

American Academy of Pediatrics (AAP)
AAP developed the medical home model for delivering primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective to all children and youth, including children and youth with special health care needs.

Agency for Healthcare Research and Quality (AHRQ)
The medical home model holds promise as a way to improve health care in America by transforming how primary care is organized and delivered. Building on the work of a large and growing community, AHRQ defines a medical home not simply as a place but as a model of the organization of primary care that delivers the core functions of primary health care. The medical home encompasses five functions and attributes: patient-centered care; comprehensive care; coordinated care; superb access to care; a system-based approach to quality and safety.

Although various organizations differ on the exact definition of a PCMH most agree that PCMH is a model of primary care that encompasses at least some or all of the following functions and attributes (listed in alphabetical order):

  • Access to Care
  • Comprehensive Care
  • Coordinated Care
  • Evidence-based Care
  • Patient-centered Care
  • Payment Structures that Recognize the Value of Primary Care
  • Quality Care
  • Safe Care
  • Systems-based Approach to Care
  • Team-based Care

Joint Principles of the Patient-Centered Medical Home was issued by AAFP, AAP, ACP, and AOA in March 2007 and is available in the following document:

The principles of PCMH have evolved since the issuance of the Joint Principles of the Patient-Centered Medical Home in 2007. One significant change, at the urging of community health centers, is that nurse practitioners, not just physicians, are now recognized as primary care clinicians in a medical home.


Health centers can become a PCMH by obtaining PCMH recognition or accreditation from one of the following three programs:

Accreditation Association for Ambulatory Health Care (AAAHC)

National Committee for Quality Assurance (NCQA)

The Joint Commission (TJC)

Each of these recognition/accreditation programs has a tool for completing the process, as well as educational programs.

The document Federal Patient-Centered Medical Home (PCMH) Collaborative, Catalogue of Federal PCMH Activities as of March 2011 provides an overview of HRSA’s current strategic goals, areas of activity, pilot programs, and technical assistance related to PCMH.

HRSA’s Accreditation and PCMH Recognition Initiative provides resources for health centers to achieve PCMH recognition. Health centers must complete a Notice of Intent (NOI) to HRSA to receive HRSA support. The NOI will be processed and reviewed for organizational readiness to undertake the PCMH survey review process.

The HRSA Program Assistance Letter (PAL) 2022-04 describes the HRSA Accreditation and PCMH Recognition Initiative and outlines the process and requirements for applying for ambulatory health care accreditation and/or PCMH recognition. The PAL extends support for PCMH recognition to health center program look-alikes (LALs).

On March 8, 2011, the AAP, AAFP, ACP, and AOA released Guidelines for Patient-Centered Medical Home Recognition Programs. The new guidelines build on the Joint Principles adopted in 2007 (see above). Included are 13 guidelines that describe important elements considered essential for effective PCMH recognition programs.

NCQA also offers the following recognition programs in addition to its PCMH Recognition Program:
Back Pain Recognition Program
Diabetes Recognition Program
Heart/Stroke Recognition Program
Patient-Centered Connected Care


There are many resources available to health centers desiring to become a recognized or accredited PCMH. There are four basic steps in starting the process of becoming a PCMH:

1. Become Aware
Become aware of the PCMH model and the various recognition/accreditation programs available. You will find information about the PCMH model, recognition/accreditation, and many other resources on this webpage. Find out if your regional/state primary care association (PCA) has any PCMH collaborative or learning team activities that your health center may participate in. Most PCAs are offering training and/or technical assistance on becoming a recognized/accredited PCMH. You may also want to become aware of the various consulting organizations that can help your health center walk through the process of becoming a PCMH (see the PCMH Consulting Services section below). Many CHCs and PCAs are hiring consultants to help them through the PCMH process.

 2. Assess Your Readiness
Every health center should perform a basic assessment of readiness before applying to a PCMH recognition or accreditation program. There are several tools available to assess your health centers readiness and are listed in the Self-Assessment Tools for Determining PCMH Readiness section below.

 3. Choose a Recognition/Accreditation Program and Necessary Support Services
Decide which recognition/accreditation program will best fit your health center. Depending on which program you choose, you may also need to decide which level and year of certification you would like to aim for. Criteria for choosing a recognition/accreditation program include the following: Medicaid and/or Medicare reimbursement and incentives in your state that may be tied to a specific recognition/accreditation program; HRSA support and assistance for each program; applicability to frontier, rural, and/or isolated areas; accreditation that your health center already holds or may be applying for. This is also a good time to determine if you will participate in any collaborative or learning team activities, and/or if you will hire a consultant to help you through the process.

 4. Prepare for a Rigorous Process and Form a Core Team
It often takes six or more dedicated months for a health center to complete a PCMH application process. There are usually many systems, processes, policies, and teams that a health center will need to develop to pass a PCMH program. Prepare your entire health center for this process and form a core team that will be committed to your health center gaining PCMH status.


There are tools available at no cost that CHCs can use to determine if they are ready to embark on the recognition/accreditation process of becoming a PCMH. Following are a few of the self-assessment tools available.

Assessing and Increasing Readiness for Patient-Centered Medical Home Implementation
Robert Wood Johnson Foundation
Evaluation summary prepared under Robert Wood Johnson Foundation’s Aligning Forces for Quality (AF4Q) initiative

Patient-Centered Medical Home Assessment (PCMH-A), Public Copy
MacColl Institute for Healthcare Innovation
Survey designed to help practices move toward state-of-the-art in delivering PCMH care by using results from the survey to identify areas for improvement


Building Your Medical Home Toolkit
National Center for Medical Home Implementation, American Academy of Pediatrics (AAP)
Free toolkit that supports development and/or improvement of a pediatric medical home by preparing practices to apply for and potentially meet the NCQA recognition requirements, including a crosswalk between the toolkit building blocks and the NCQA “must pass” elements

Creating a Place for Care: Fostering Alignment and Eliminating Barriers in the Patient-Centered Medical Home
2016 Resource
Capital Link
Provides health centers with insight on how to respond to and reflect the unique needs and preferences of the patients they serve in order to align their facility with their process of care and the people they support

Crosswalk – NCQA 2014 PCMH – HRSA 19 Requirements – Meaningful Use
2014 Crosswalk
Compares NCQA 2014 PCMH recognition standards, HRSA 19 requirements, and Meaningful Use requirements to help CHCs plan, organize and implement processes that satisfy requirements for multiple purposes

Developing an Organizational Culture that Sustains the Patient-Centered Medical Home
2016 Resource
Capital Link
Examines the cultural challenges and successes health centers face in sustaining the PCMH model of primary care delivery. It offers considerations for enhancing the patient, family, and staff experience and suggests flexible organizational structures to support team-based care delivery

Fostering Partnership and Teamwork in the Pediatric Medical Home Video Series
National Center for Medical Home Implementation
A “How To” Video Series including Part 1 Team Huddles, Part 2 Family Advisory Groups, and Part 3 Care Partnership Support

Health IT Success Stories
Agency for Healthcare Research and Quality (AHRQ)
Best practice, quality improvement programs shown on video including Electronic Standing Orders Empower Medical Staff and Improve Delivery of Care, and Improving Care Transitions for Patients with Complex Health Needs through Decision Support

Implementation Guide Series by Change Concept
Safety Net Medical Home Initiative
Guides and tools based on the experience of the 65 CHC sites that participated in the Safety Net Medical Home Initiative, by change concepts including Empanelment, Team-Based Healing Relationships, Patient-Centered Interactions, Engaged Leadership, QI Strategy, Enhanced Access, Care Coordination, and Organized, Evidence Based Care

Optimizing the Care Team Tool and The Evidence Base for SNMHI (Safety Net Medical Home Initiative) Change Concepts
Community Health Association of Mountain/Plains States (CHAMPS)
Handout and follow-up document for the webcast Patient Care Teams: Transforming the Primary Care Practice presented in June 2013

Patient Visit Redesign, How to Start
Patient Visit Redesign
Tools to guide health centers through patient visit redesign including step-by-step guides, visit tracking toolkit, visit mapping toolkit, and baseline data toolkit

PCMH Resource Center
Agency for Healthcare Research and Quality (AHRQ)
Resource center provides a definition and evidence for PCMH including papers, briefs, and evaluation tools as well as resources for implementing PCMH


To view and download samples of policies/procedures and PCMH recognition documentation, click on this CHAMPS webpage:

Note: If your health center has any policies, procedures, or other documents to share that would help other Region VIII CHCs in adopting PCMH standards, please contact the CHAMPS Clinical Quality Improvement Director.


Comprehensive Primary Care Initiative
Centers for Medicare & Medicaid (CMS), Center for Medicare and Medicaid Innovation
CMS initiative, announced September 28, 2011, will foster collaboration between public and private health care payers to strengthen primary care by testing a service delivery model, which includes risk-stratified care management, access and continuity, planned care, patient and caregiver engagement, and coordination of care, and by testing a payment model that will include a case management fee paid to selected primary care practices 

Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration Project
Demonstration project operated by CMS in partnership with HRSA aims to show how the PCMH model can improve quality of care, promote better health, and lower costs by helping FQHCs invest in patient care and infrastructure as described in the following news release

Patient-Centered Outcomes Research Institute (PCORI)
Created to conduct research to provide information about best available evidence to help patient and providers make more informed decsions through research funding opportunities which are posted on the following webpage

Safety Net Medical Home Initiative
Commonwealth Fund, Qualis Health, and MacColl Institute
Five-year demonstration project initiated in 2008 to assist safety net primary care clinics in becoming high-performing PCMHs through partnerships between safety net providers and community stakeholders with five Regional Coordinating Centers being selected to participate with each including 12-15 safety net clinics in their area:

State Pilot Projects in the U.S.
Patient-Centered Primary Care Collaborative (PCPCC)
Listing of state PCMH projects, in safety net and multi-payer sites, across the U.S. listed by project, state, and start date


Archived Webinars
Patient-Centered Primary Care Collaborative (PCPCC)
Free webinar replays and slides for a multitude of presentations on PCMH including infrastructure, approaches to coordinated care, health information technology, behavioral health integration, training the workforce, and a PCPCC website walkthrough

Change Concepts
Qualis Health
Free guides, slide presentations, and videos on eight change concepts including Empanelment, Team-Based Care, Patient-Centered Interactions, Engaged Leadership, QI Strategy, Enhanced Access, Care Coordination, and Organized Evidence Based Care

NCQA Recognition Training Programs
Free links to slide presentations including Getting On Board, Standards 1-3, and Standards 4-6 presented by NCQA


Evaluation of CMS’ FQHC APCP Demonstration, Final First Annual Report
Centers for Medicare & Medicaid Services (CMS)
February 2015

The Evidence Base for SNMHI (Safety Net Medical Home Initiative) Change Concepts
Safety Net Medical Home Initiative
February 2013

Benefits of Implementing the Primary Care Patient-Centered Medical Home: A Review of Cost & Quality Results, 2012
Patient-Centered Primary Care Collaborative (PCPCC)

Patient-Centered Medical Home Recognition Tools: A Comparison of Ten Surveys’ Content and Operational Details
The Urban Institute
March 2012

Results from 2010-11 Readiness for Meaningful Use of HIT and Patient-Centered Medical Home Recognition Survey
Geiger Gibson/RCHN Community Health Foundation Research Collaborative, Policy Research Brief #27
November 3, 2011

Developing Federally Qualified Health Centers into Community Networks to Improve State Primary Care Delivery Systems
The Commonwealth Fund
May 2011

Community-Centered Health Homes: Bridging the Gap Between Health Services and Community Prevention
Prevention Institute
February 2011

Family Medicine: Preparing for a High-Performance Health Care System
K. Davis, PhD, and K. Stremikis, MPP, JABFM, Vol. 23 Supplement
March-April 2010

Context for Understanding the National Demonstration Project and the Patient-Centered Medical Home
K. C. Stange, MD, PhD, et al., Annals of Family Medicine, Vol. 8, Supplement 1

Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home
P. A. Nutting, MD, MSPH, et al., Annals of Family Medicine, Vol. 7, No. 3
May/June 2009

Proof in Practice
Patient-Centered Primary Care Collaborative (PCPCC)


Please note, CHAMPS does not endorse any of the following consultation services. This listing contains services that are being utilized by CHCs and private primary care practices throughout the nation. It is wise when considering a consultation service to inquire about other similar clients and ask to speak to those clients about the work performed and the level of satisfaction.

Arcadia Solutions



Primary Care Development Corporation (PCDC)

Qualis Health

Quality First Healthcare Consulting, Inc. (QFHC)

Patient Satisfaction/Experience Surveys and Patient Activation/Engagement Resources

To view information about patient satisfaction/experience surveys and patient activation/engagement click on the following CHAMPS webpage:

Note: If your health center has any patient satisfaction/experience surveys or other documents to share, that would help Region VIII health centers implement patient satisfaction/experience surveys and/or achieve greater patient activation/engagement, please contact the CHAMPS Clinical Quality Improvement Director.