The Agency for Healthcare Research and Quality (AHRQ) has a new website specific to the patient-centered medical home. One of the key resources is a citations database of journal articles, reports, policy briefs, and position statements on the medical home. Click here to access.

The American Academy of Family Physicians (AAFP) has gathered a comprehensive collection of information and resources to assist practices in becoming complete Patient-Centered Medical Homes.

The American College of Physicians (ACP) provides information on understanding the Patient-Centered Medical Home, including cost, benefits and incentives, and links to tools and resources.

TransforMED, an affiliate of AAFP, is focused on studying and implementing transformed models of high performance practices that meet the needs of both patients and practices. For information on their Medical Home Products and Services click here. To review TransforMED working papers click here.

Guided Care® is a model of comprehensive chronic care that has been tested in multiple primary care practices. This model places a specially educated nurse in a primary care practice to enhance the care of the sickest patients. The Guided Care model is one choice to help practices function as advanced medical homes.

The National Committee for Quality Assurance’s (NCQA) Physician Practice Connections® – Patient-Centered Medical Home (PPC®-PCMH™-CMS) program builds upon NCQA’s current Physician Practice Connections program to recognize primary care practices that function as patient-centered medical homes. Building on the joint principles developed by the primary care specialty societies, the PPC-PCMH™-CMS is used to qualify practices or medical homes for the Medicare Medical Home Demonstration.

The Patient-Centered Primary Care Collaborative is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and many others who have joined together to develop and advance the patient-centered medical home concept. The Collaborative has well over 200 members. The Collaborative believes that, if implemented, the patient-centered medical home will improve the health of patients and the viability of the health care delivery system. In order to accomplish this goal, employers, consumers, patients, physicians and payers have agreed that it is essential to support a better model of compensating physicians.
View PCPCC’s Pilot projects
View PCPCC’s Purchaser’s Guide
View PCPCC’s HIT Resource Guide

Medical Home News is a monthly newsletter for health care professionals interested in Patient Centered Medical Homes. Medical Home News is published by Health Policy Publishing LLC.

The National Transitions of Care Coalition (NTOCC) has many tools, resources, and best practices for health care professionals to help enhance transitions of care. Click here for details.

The Chronic Disease Self-Management Program (CDSMP), developed by Dr. Kate Lorig and her colleagues at Stanford University's Patient Education Research Center, is a key resource for providers in meeting the requirements to become a Medicare Medical Home. Through a partnership with the U.S. Administration on Aging (AoA) and the Atlantic Philanthropies (AP), the National Council on Aging (NCOA) has introduced Stanford's CDSMP to 27 states. Click here for more information about CDSMP. Click here for a map from Stanford University of CDSMP-licensed organizations by state, and click here for a description of CDSMP in states working with NCOA.

Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a national initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home. Visit for many resources, including a clinical toolkit, data collection tools, project management tools, and educational tools.

The Chronic Disease Electronic Management System (CDEMS) is an easy-to-use free registry designed to assist medical providers in managing and reporting on patients with chronic health conditions. Visit for details.

The Change Concepts support the Patient-Centered Medical Home model of care in the Safety Net Medical Home Initiative, click here for details.

Patient Education
Emmi Solutions, TransforMED and the PCPCC
have partnered to create a web-based patient education tool designed to play an integral role in the transformation of primary care practices to Patient-Centered Medical Homes. The result is an engaging and educational multimedia experience that helps patients understand the Patient-Centered Medical Home and their role in this collaborative health and wellness relationship with their primary care practice. Click here to learn more and to put this patient education tool on your website for FREE.

The Center for the Advancement of Health developed a resource titled “Creating a Patient Guide for ‘Medical Home’ Physician Practice. Click here for details.

Other resources are available on the Patient-Centered Primary Care Collaborative website, see the ‘Consumer & Patients’ tab in the left menu bar.

The National Transitions of Care Coalition (NTOCC) has many tools and resources for patients and families about care transitions. Click here for more information.

"Transformation: A Family's Guide to Chronic Care, Guided Care, and Hope" by Tom Grundner, Ed.D., is a short book that describes to chronically ill patients and their families what Guided Care is and how it can help them. It is not the standard patient education book!

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