Table 3

Selected Patient-Centered Medical Home Characteristics of Practices (N = 94)

PCMH CharacteristicPercent or Mean (SD)
Dimension 1: Each patient has a personal physician
Patients usually/always see the same cliniciana90
All patients in the practice can identify their primary care clinician or care team by name57
Dimension 2: Whole-person orientation
Clinician includes an adult patient’s family in discussion of his/her health
Clinician discusses diet and exercise guidelines with patients
Clinician discusses depression with patients
Clinician discusses stress and anxiety with patients
Clinician discusses alternative treatments with patients
Clinician discusses family planning or birth control services with patients
Resources used for translation with patients who cannot communicate well in English
 Family member63
 On-site bilingual clinical staff62
 On-site bilingual nonclinical staff17
 Telephone-based translation service6
Languages in which patient education materials are made available
Amount of formal training that practice staff have used to improve their skills in patient communication or cultural competence
 Little or none47
 Great deal18
Dimension 3: Team-based care
Formal care teams in place18
Informal care teams in place57
Nonclinician staff educate patients about prevention, chronic illness, and/or depression43
Practice staff meet to review and plan care for individual patients
 At least weekly10
 At least monthly33
 Less than monthly47
Practice holds all-staff meetings
 Once a year12
 Once a quarter29
Practice staff have “huddle” meetings in which operational strategies and/or division of labor is determined45
Nonclinician staff provide patient education
Nonclinician staff take patient history
Nonclinician staff perform chronic disease screening
Clinicians speak to primary care clinicians outside of their practices about cases
Dimension 4: Care coordinated and integrated across health care system
Designated care or case manager7
Nondesignated staff functioning as care or case manager55
Use electronic prescribing94
Have structured processes in place for:
 Reminding patients of upcoming appointments87
 Following up with patients who have missed appointments81
 Contacting patients who have not been seen in ≥1 year59
 Systematically monitoring patients with chronic conditions82
Clinician shares clinical information with specialists
Clinician follows up directly with specialists if aware of visit
Clinician talks with patients about the results of their visit(s) to specialist(s)
Clinician finds out their patients are in the hospital during their hospitalizations
Clinician sees patients during their hospitalizations
Clinician receives discharge summary for patients who have been hospitalized
Practice refers patients to community smoking cessation programs
Practice refers patients to community diabetes education
Practice refers patients to community mental or behavioral health counseling
Practice refers patients to community patient support groups
Have developed QI process(es) to improve patient satisfaction57
Dimension 5: Focus on quality and safety
Practice has clinical care guidelines for preventive care
 Yes, without using EHR32
 Yes, using EHR63
Practice has clinical care guidelines for ≥1 chronic diseases
 Yes, without using EHR32
 Yes, using EHR63
Practice has clinical care guidelines for depression
 Yes, without using EHR26
 Yes, using EHR63
Practice uses a formal process to measure performance of individual clinicians29
Practice uses a formal process to measure performance of the entire practice34
Practice has developed a plan for improving patient care processes or outcomes40
Practice has used clinical data to assess the impact of QI efforts55
Practices uses PDSA or rapid cycle testing9
Amount of time clinician spends on patient education during a typical visit
 A little8
 A moderate amount54
 A lot38
Dimension 6: Timely access to care and communication
Clinicians communicate with patients via e-mail37
Use open access or advanced access scheduling61
Business days a patient with nonurgent needs will wait to see their clinician, No.1 (0.2)
In-office wait time for scheduled appointments, min28 (16)
Clinicians can respond to patients who call outside of regular office hours
Clinicians can return patient calls about medical issues received during office hours by the end of that same day
Practice arrangements for patients to see a doctor or nurse for nonemergent problems on evenings and/or weekends without going to the emergency department
 Practice is open some evenings and/or weekends68
 Have made arrangements with other practices4
 Have made arrangements with ≥1 urgent care center(s)5
 No specific arrangements14
PCMH recognition and related incentives
 Have not applied for PCMH recognition32
 Application pending19
 Receiving medical home/PCMH incentives38
 Receiving HIT/meaningful use incentives59
 Receiving QI/performance incentives from health plan27
  • EHR = electronic health record; HIT = health information technology; PCMH = patient-centered medical home; PDSA = Plan, Do, Study, Act; QI = quality improvement.

  • Note: Clinicians refers to medical doctors, doctors of osteopathy, nurse practitioners, or physician assistants.

  • a Question asked only of respondents who identified themselves as not solo practitioners as it was assumed that in a solo practice patients would necessarily seem the same physician every time.