PCMH Resources for Researchers

Use information in this section to improve evaluations of the medical home. This information is designed especially for PCMH researchers and evaluators.

What are strategies and best practices for evaluating primary care interventions?

In this section, find resources that include:

  • Papers describing what we know about the medical home and its effects and areas in which further research is needed
  • A series of briefs to "expand the toolbox" of methods to evaluate and help refine PCMH models and other primary care delivery interventions
  • A guide for evaluators that presents practical steps for designing an evaluation of primary care interventions.
  • Searchable databases designed to assist researchers in evaluating crucial components of the medical home, including patient-centeredness, care coordination, the medical neighborhood, team-based care, and behavioral health integration.

PCMH Resources for Researchers

Series Overview


White Papers

Engaging Patients and Families in the Medical Home
(PDF Version — 526.27KB) PDF Help
A key element of the PCMH model is engaging patients and caregivers in their care. This paper offers policymakers and researchers insights into opportunities to engage patients and families in the medical home and includes a framework for conceptualizing opportunities for engagement. It also reviews the evidence base for these activities, and offers examples of existing efforts as well as implications for policy and research.


Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care
(PDF Version — 752KB) PDF Help
Practice-Based Population Health is an approach to care that uses information on a group of patients within a primary care practice(s) to improve the care and clinical outcomes of patients within that practice. This report describes this approach and discusses the information management functionalities that may help primary care practices to move forward with this type of proactive management.

More reports are available in the section below titled "Searchable Databases of Instruments and Measures."

Guide for Evaluators

Searchable Databases of Instruments and Measures

Primary Care Measures Databases: Resources for Research and Evaluation
Are you looking for instruments and measures to study and evaluate interventions to improve primary care? Use these searchable databases to explore frameworks for measurement, and to identify and compare measures within 4 areas that are critical to primary care improvement. For each database, there is a companion Atlas report available.

Care Coordination Measures Database
(PDF Version — 2.2MB) PDF Help
Care coordination is considered a core function in the provision of patient-centered, high-value, high-quality primary care. However, challenges remain in measuring the structural and process aspects of care coordination, as well as its contributions to desired outcomes. The Care Coordination Measures Database (CCMD) is designed to assist evaluators and researchers by providing comprehensive profiles of existing measures of care coordination; organizing those measures along two dimensions (domain and perspective); and presenting a framework for understanding care coordination measurement, to which the measures are mapped. This framework incorporates elements from other proposed care coordination frameworks and is designed to support development of the field. Users of the CCMD can compare more than 90 validated care coordination measurement tools to identify and select those that are most appropriate for their research and evaluation needs.

Clinical-Community Relationships Measures Database
(PDF Version — 1.8MB) PDF Help
Understanding primary care’s role in the medical neighborhood and in improving population health, as well as the health of individual patients, is an increasingly important aspect of primary care transformation. Relationships among patients, primary care clinics/clinicians, and community resources can be measured. However this has been an understudied aspect of primary care services. In the context of the Clinical-Community Relationships Measures Database (CCRM Database), a clinical-community relationship exists when a primary care clinician makes a connection with a community resource to provide certain preventive services such as tobacco screening and counseling. The clinical practice and the community resource may engage by networking, coordinating, cooperating, or collaborating. The CCRM Database provides a framework for understanding the measurement of clinical-community relationships and provides information about existing measures, as well as links to resources to improve CCRM research and implementation.

Team-Based Primary Care Measures Database
(PDF Version — 857KB) PDF Help
Successful primary care redesign efforts such as the Patient-centered Medical Home require a high-functioning primary care team that delivers team-based care. Team-based primary care holds promise as a way to improve patient outcomes, care processes, and patient and provider experiences of care. However, a better understanding of how teams should function is needed, which in turn requires a strong theoretical conceptual framework and validated measures, specific to and appropriate for use in the primary care setting. Having robust measures of team-based care appropriate to the primary care setting is critical to evaluating and improving team function and patient outcomes. The Team-based Care Measures Database is an inventory of instruments that provides a conceptual framework for team-based primary care and profiles of over 40 instruments for use in research and evaluation.

Atlas of Integrated Behavioral Health Care Quality Measures
(PDF Version — 247KB) PDF Help
Integrated behavioral health care can systematically enhance the ability of primary care practices to address behavioral health issues that naturally emerge in the primary care setting, prevent fragmentation between behavioral health and medical care, and create effective relationships with mental health specialists. As greater numbers of practices and health systems begin to design and implement integrated behavioral health services, there is a growing need for quality measures that are rigorous and appropriate to the specific characteristics of different approaches to integration. The IBHC Measures Atlas supports the field of integrated behavioral health care measurement by presenting a framework for understanding measurement of integrated care; providing a list of existing measures relevant to integrated behavioral health care; and organizing the measures by the framework and by user goals to facilitate selection of measures.

Survey Tools


The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care

Research Articles