Table 3

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

PCMH Characteristic	Percent or Mean (SD)
Dimension 1: Each patient has a personal physician
Patients usually/always see the same clinician^a	90
All patients in the practice can identify their primary care clinician or care team by name	57
Dimension 2: Whole-person orientation
Clinician includes an adult patient’s family in discussion of his/her health
Never/rarely	7
Sometimes	49
Usually	34
Always	10
Clinician discusses diet and exercise guidelines with patients
Never/rarely	0
Sometimes	2
Usually	37
Always	61
Clinician discusses depression with patients
Never/rarely	0
Sometimes	19
Usually	53
Always	28
Clinician discusses stress and anxiety with patients
Never/rarely	0
Sometimes	20
Usually	54
Always	26
Clinician discusses alternative treatments with patients
Never/rarely	17
Sometimes	43
Usually	20
Always	20
Clinician discusses family planning or birth control services with patients
Never/rarely	18
Sometimes	42
Usually	21
Always	19
Resources used for translation with patients who cannot communicate well in English
Family member	63
On-site bilingual clinical staff	62
On-site bilingual nonclinical staff	17
Telephone-based translation service	6
Languages in which patient education materials are made available
English	96
Spanish	68
Other	20
Amount of formal training that practice staff have used to improve their skills in patient communication or cultural competence
Little or none	47
Some	29
Great deal	18
Dimension 3: Team-based care
Formal care teams in place	18
Informal care teams in place	57
Nonclinician staff educate patients about prevention, chronic illness, and/or depression	43
Practice staff meet to review and plan care for individual patients
Daily	10
At least weekly	10
At least monthly	33
Less than monthly	47
Practice holds all-staff meetings
Never	15
Once a year	12
Once a quarter	29
Monthly	34
Weekly	10
Practice staff have “huddle” meetings in which operational strategies and/or division of labor is determined	45
Nonclinician staff provide patient education
Never/rarely	28
Sometimes	42
Usually	16
Always	10
Nonclinician staff take patient history
Never/rarely	45
Sometimes	23
Usually	12
Always	16
Nonclinician staff perform chronic disease screening
Never/rarely	70
Sometimes	16
Usually	7
Always	2
Clinicians speak to primary care clinicians outside of their practices about cases
Never/rarely	21
Sometimes	49
Usually	19
Always	11
Dimension 4: Care coordinated and integrated across health care system
Designated care or case manager	7
Nondesignated staff functioning as care or case manager	55
Use electronic prescribing	94
Have structured processes in place for:
Reminding patients of upcoming appointments	87
Following up with patients who have missed appointments	81
Contacting patients who have not been seen in ≥1 year	59
Systematically monitoring patients with chronic conditions	82
Clinician shares clinical information with specialists
Never/rarely	1
Sometimes	18
Usually	39
Always	42
Clinician follows up directly with specialists if aware of visit
Never/rarely	0
Sometimes	42
Usually	35
Always	23
Clinician talks with patients about the results of their visit(s) to specialist(s)
Never/rarely	1
Sometimes	9
Usually	31
Always	59
Clinician finds out their patients are in the hospital during their hospitalizations
Never/rarely	2
Sometimes	27
Usually	50
Always	21
Clinician sees patients during their hospitalizations
Never/rarely	36
Sometimes	24
Usually	14
Always	24
Clinician receives discharge summary for patients who have been hospitalized
Never/rarely	3
Sometimes	23
Usually	47
Always	27
Practice refers patients to community smoking cessation programs
Never/rarely	14
Sometimes	44
Usually	19
Always	23
Practice refers patients to community diabetes education
Never/rarely	9
Sometimes	31
Usually	29
Always	31
Practice refers patients to community mental or behavioral health counseling
Never/rarely	5
Sometimes	36
Usually	32
Always	27
Practice refers patients to community patient support groups
Never/rarely	26
Sometimes	44
Usually	17
Always	12
Have developed QI process(es) to improve patient satisfaction	57
Dimension 5: Focus on quality and safety
Practice has clinical care guidelines for preventive care
No	5
Yes, without using EHR	32
Yes, using EHR	63
Practice has clinical care guidelines for ≥1 chronic diseases
No	7
Yes, without using EHR	32
Yes, using EHR	63
Practice has clinical care guidelines for depression
No	11
Yes, without using EHR	26
Yes, using EHR	63
Practice uses a formal process to measure performance of individual clinicians	29
Practice uses a formal process to measure performance of the entire practice	34
Practice has developed a plan for improving patient care processes or outcomes	40
Practice has used clinical data to assess the impact of QI efforts	55
Practices uses PDSA or rapid cycle testing	9
Amount of time clinician spends on patient education during a typical visit
A little	8
A moderate amount	54
A lot	38
Dimension 6: Timely access to care and communication
Clinicians communicate with patients via e-mail	37
Use open access or advanced access scheduling	61
Business days a patient with nonurgent needs will wait to see their clinician, No.	1 (0.2)
In-office wait time for scheduled appointments, min	28 (16)
Clinicians can respond to patients who call outside of regular office hours
Never/rarely	5
Sometimes	4
Usually	18
Always	72
Clinicians can return patient calls about medical issues received during office hours by the end of that same day
Never/rarely	1
Sometimes	1
Usually	27
Always	71
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 weekends	68
Have made arrangements with other practices	4
Have made arrangements with ≥1 urgent care center(s)	5
Other	17
No specific arrangements	14
PCMH recognition and related incentives
Have not applied for PCMH recognition	32
Application pending	19
Receiving medical home/PCMH incentives	38
Receiving HIT/meaningful use incentives	59
Receiving QI/performance incentives from health plan	27

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.