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Module 1: Getting Started—Selecting Sites, Structuring Interventions

Learning objectives


Action steps and tools

Learning objectives

  • Articulate why PCMH transformation is not "business as usual" and ways to support it
  • Establish a relationship with practices
  • Take a step-by-step approach to establish a plan of action that supports long-term improvement



Patient-centered medical home transformation usually means big changes to how practices organize and provide care and even how team members work together. Practice facilitation is a proven way to support practice transformation. It works best when it builds on:

  • Motivated practices
  • A tailored plan that accounts for each practice's unique resources and environment
  • A good relationship and clearly defined roles and responsibilities between the coach and the practice

This module provides approaches and tools to help you establish a relationship with a practice and kick start your work together. As you get going, encourage the practice to engage in peer-to-peer learning as much as possible. Coach Medical Home Module 5 provides tips and resources for starting a learning community.

Action steps and tools

Action step Tool

Hone your coaching skills

AHRQ Patient-Centered Medical Home Resource Center
Includes a practice facilitation "How-to Guide" with a range of practical tips and case studies for practice facilitation programs—plus information about joining AHRQ's practice facilitation learning community.

Introduce the PCMH

Health Reform and the Patient-Centered Medical Home: Policy Provisions and Expectations of the Patient Protection and Affordable Care Act
Summarizes the Affordable Care Act’s provisions that relate to the PCMH put together for coaches and practices in the Safety Net Medical Home Initiative.

Video on Becoming a Medical Home

An entertaining way to present the PCMH.

Guiding Transformation: How Medical Practices can become Patient-Centered Medical Homes

Commonwealth Fund Issue brief describing PCMH components.

Change Concepts, NCQA Standards and PCMH-A Crosswalk

Build a relationship

Implementing the Patient-Centered Medical Home Model: A Practice Facilitator's Guide to Visiting Clinical Teams
Practical information on working with practices at different levels of readiness, planning the first practice visit, developing an agenda for the meeting, and initial activities following the kick-off.

Assess readiness

Safety Net Medical Home Initiative Self-Assessment Tool.

Establish a plan of action

Sample Memorandum of Agreement
To clarify facilitator and practice roles and responsibilities. Courtesy of L.A. Net.

PCMH Calendar Tool

Calendar planning tool to help you plan for the work the practice will need to undertake.

Provide practices with tools they can use

Safety Net Medical Home Initiative
Contains a wealth of corresponding tools and information for practices, including a series of detailed implementation guides.


Additional reading

Baskerville NB et al. 2012. Systematic review and meta-analysis of practice facilitation within primary care settings. Ann Fam Med 10(1):63-74.

Miller WL et al. 2010. Primary care practice development: a relationship-centered approach. Ann Fam Med 8 Suppl 1:S68-79; S92

Nutting PA et al. 2009. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med 7(3):254-60.

Nutting PA et al. 2011. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood) 30(3):439-45.

Reid RJ et al. The group health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010 May;29(5):835-43.

Wise CG, Alexander JA, Green LA, et al. Journey toward a Patient-Centered Medical Home: Readiness for Change in Primary Care Practices. Milbank Q. Sep 2011;89(3):399-424.