Change Concepts for Practice Transformation

Building a Patient Centred Medical Home (PCMH) requires: engaged leadership; a quality improvement strategy; empanelment (patient registration); continuous and team-based healing relationships with patients; organised, evidence-based care; patient-centred interactions; enhanced access to care; and care coordination. (1)

These change concepts and associated key changes were tested in a 5-year demonstration project in 65 practices in the United States, as part of the Safety Net Medical Home Initiative. (2) This initiative was conducted through the Commonwealth Fund, Qualis Health, and the MacColl Center for Health Care Innovation at the Group Health Research Institute.

Change concepts are general ideas used to stimulate specific, actionable steps that lead to improvement.

Change conceptDescription Key changes
Engaged leadership Engaged leadership requires visible leadership that can establish a quality improvement apparatus and culture; help staff envision a better organisation and improved care; and ensure staff have the time and training to work on system change.
  • Provide visible leadership for culture change and quality improvement.
  • Ensure time and resources for transformation are available.
  • Ensure there is protected time for quality improvement.
  • Build PCMH values into staff hiring and training.
Quality improvement strategy This strategy relies on routine performance management to identify opportunities for improvement, and uses rapid-cycle change methods to test ideas for change. It obtains and uses patient experience data to inform improvement efforts, to make the practice more responsive to patient needs and preferences. Practices put in place information systems to support performance management, and provide alerts and reminders, computerised order entry, and population management.
  • Use a formal quality improvement model.
  • Establish metrics to evaluate improvement.
  • Involve patients, families, and staff in quality improvement.
  • Optimise the use of health information technology.
Empanelment (patient registration) Care provided by the same clinician and care team over time results in positive outcomes. Linking each patient and family with a provider facilitates continuity of relationships, a cornerstone of the PCMH model. Practice teams can monitor their panel to identify patients who require more attention and services. In the Australian healthcare environment, empanelment, whereby an individual is linked to a specified practice, is referred to as patient registration. The practice the patient is linked to functions as their home care provider. It serves as a single point of contact for care provision in the primary setting and for coordination with other health services.
  • Assign all patients to a provider panel.
  • Assess supply and demand to balance patient and caseloads.
  • Use panel data to manage patient populations by tracking and monitoring care needs and health status.
  • The panel has a level of responsibility for patients’ healthcare even when patients are not seen face-to-face.
Continuous and team-based healing relationships Robust and lasting patient-clinician relationships are central to the medical home. This begins with defining critical roles and tasks involved, assigning them to the most appropriate member of the team (clinical and non-clinical), and ensuring the team member is trained to perform them well.
  • Establish and support care delivery teams.
  • Link patients to the provider and care team.
  • Ensure patients see their provider.
  • Distribute roles and tasks among team members.
Organised, evidence-based care This includes planned care and decision support. Information system tools enable practices to identify gaps in care for patients, before they visit. Decision support systems improve care by alerting providers when services are needed, and helping them make evidence-based choices.
  • Use planned care according to patient need.
  • Manage care for high-risk patients.
  • Use point-of-care reminders.
  • Use patient data to enable planned interactions.
Patient-centred interactions These interactions increase patients’ involvement in decision-making, care and self-management. They respect a patient’s needs, preferences and values, and work to ensure patients understand what is being communicated to them.
  • Respect patient and family values and needs.
  • Encourage patient involvement in health and care.
  • Communicate clearly so that patients understand.
  • Provide self-management support at every encounter.
  • Obtain patient and family feedback and use this for quality improvement.
Enhanced access Patients have the ability to contact their care team during and after office hours.
  • Ensure patients have 24/7 access to the care team.
  • Provide appointment scheduling options.
  • Increase availability of non-face-to-face contacts.
Care coordination This coordination helps patients find and access high-quality service providers; ensures that appropriate information flows between the PCMH and other providers; and tracks and supports patients through the process.
  • Integrate behavioural health and specialty care into care delivery through co-location or referral agreements.
  • Track and support patients when they obtain services outside the practice.


  1. The Commonwealth Fund. How medical practices can become patient-centred medical homes [Internet]. Washington: The Commonwealth Fund; 2012 [cited March 2017]. Available from:
  2. Safety Net Medical Home Initiative. Project description [Internet]. Seattle: Safety Net Medical Home Initiative; 2015 [cited July 2015]. Available from: