Table 1.

Data Sources and Indicators Used to Measure the Principles of the Patient-Centered Medical Home

PrincipleData SourceIndicator
CD = computer disk; PDA = personal digital assistant.
a 0 = never, 1 = rarely, 2=sometimes, 3 = usually, 4 = always.
b 0 = no, 1 = yes.
c 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.
d 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent.
Personal physician: ongoing relationship for first- contact, continuous, and comprehensive carePatient survey“When I get sick, I contact this practice first (before going to a specialist or emergency room).”a
 “How often do you see the same doctor when getting care at this practice?”a
Chart auditNumber of months seen at practice
 Number of visits in past 2 years
Physician-directed team: physician leads team of individuals who care for patientsDirector surveyPractice has nurse practitioners or physician assistantsb
 Use of nurses or health educators for preventive counselingb
Practice member survey“This practice encourages nursing staff input for making changes.”c
Whole-person orientation: Care for all stages of life, acute care, chronic care, preventive services, end of life careChart auditPatient has well-visit in last 5 yearsb
 Patient was treated at practice for acute illnessb
 Number of chronic diseases
Care coordination: coordinated/integrated across all elements of complex health system—within practice and between consultants, ancillary providers, and community resourcesPractice member survey“We have a system to make sure results from testing/consultation reports are available during patient visits.”c
 “We have a system for communicating results from testing to patients.”c
Director surveyUse of referral system to link patients with community programs for education, support, or preventive counselingb
 Clinicians make hospital or nursing home visitsb
Quality and safety: achieved through physician- patient partnerships, evidence-based medicine, clinical decision-support tools, continuous quality improvement, patient participation and feedback, information technology, voluntary recognition processDirector surveyUse of electronic medical recordsb
 Use of information technology (PDA, online literature searching, CD or Internet-based knowledge bases)a
 Use of clinical decision-support tools (reminder systems for identifying patients due for screening, prompting clinicians about needed tests, reminding patients about visits, checklists/flowcharts for chronic disease or screening, risk factor chart stickers or electronic flags)a
 Continuous quality improvement (use of patient satisfaction surveys, periodic chart audits)b
Enhanced access: through systems such as open scheduling, expanded hours, new options for communicationPatient survey“How long you waited to get an appointment”d
 “Getting through to the office by phone”d
Director surveyUse of e-mail with patientsb
 Use of Web site for marketingb