Skip Navigation

Strengthen the Evidence for Maternal and Child Health Programs

Sign up for MCHalert eNewsletter

Evidence Tools
MCHbest. Well-Woman Visit.

MCHbest Logo

Strategy. Medical Homes

Approach. Support the development of a medical home care model to be implemented within clinics statewide

Return to main MCHbest page >>

Overview. Patient-Centered Medical Homes (PCMHs) provide continuous, comprehensive, primary care. In this model of care, primary care providers and their teams coordinate care across the healthcare system, working with patients to address all their preventive, acute, and chronic health care needs. Arranging care with other qualified health professionals as needed, medical homes offer enhanced access, expanded hours, and easy communication options for patients.

Evidence. Scientifically Rigorous Evidence. Strategies with this rating are most likely to be effective...

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source.

Potential Data Sources. Data to support this strategy can be accessed through:

  • Clinic self-assessment and readiness data
  • Clinic operational data
  • Patient satisfaction surveys and feedback

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Patient Experience of Care. This study improves individuals' perceptions, feelings, and satisfaction with the healthcare services they receive.
  • Access to/Receipt of Care. This strategy increases the ability for individuals to obtain healthcare services when needed, including preventive, diagnostic, and treatment services.
  • Quality of Care. This strategy promotes the degree to which healthcare services meet established standards aimed at achieving optimal health outcomes.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Health Teaching (Education and Promotion) (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy or aligned components.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the RBA framework (see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort (“What/how much did we do?”)

  • Number of clinics statewide that adopt and implement the Patient-Centered Medical Home (PCMH) model of care. (Measures the spread and uptake of the PCMH model across the healthcare system)
  • Number of patients enrolled in PCMH clinics, disaggregated by demographics, health conditions, and geographic location. (Measures the reach and penetration of PCMH services among different populations)

Quadrant 2:
Measuring Quality of Effort (“How well did we do it?”)

  • Percent of PCMH clinics that meet established criteria for high-quality, comprehensive primary care delivery, as defined by recognized PCMH accreditation programs. (Measures the fidelity and quality of PCMH implementation)
  • Percent of primary care providers and care team members who complete training and demonstrate proficiency in PCMH core competencies, such as care coordination, population health management, and quality improvement. (Measures the effectiveness of workforce development efforts)

Quadrant 3:
Measuring Quantity of Effect (“Is anyone better off?”)

  • Number of learning collaboratives, peer mentoring programs, and technical assistance resources provided by Title V to support PCMH implementation and continuous improvement statewide. (Measures the level of system-wide support and knowledge-sharing for PCMH adoption)
  • Number of data-sharing agreements and health information exchange platforms implemented to facilitate care coordination and population health management across PCMH clinics. (Measures the use of data and technology to support PCMH effectiveness)
  • Number of patients from communities with complex health needs who receive comprehensive, coordinated care through PCMH clinics. (Measures the intervention's success in improving health)
  • Number of PCMH clinics that demonstrate sustained improvements in patient health outcomes, care quality, and efficiency over time. (Measures the long-term viability and impact of the PCMH model on transforming primary care delivery)

Quadrant 4:
Measuring Quality of Effect (“How are they better off?”)

  • Percent of PCMH clinics that implement tailored outreach and engagement strategies to enroll patients from communities with the lowest rates of preventive care utilization. (Measures the implementation of the PCMH model)
  • Percent of PCMH clinics that regularly assess and address literacy and language access needs of their patient populations. (Measures the level of patient-centered care delivery in PCMH implementation)
  • Percent increase of preventive care utilization, chronic disease management, and health outcomes between patients in PCMH clinics and those in non-PCMH clinics. (Measures the population-level impact of the PCMH model)
  • Percent of patients who report sustained engagement with their PCMH care team, improved self-management skills, and increased confidence in navigating the healthcare system over time. (Measures the long-term impact of the PCMH model on patient empowerment and health-related quality of life)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.