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Module 3: Fundamentals First—Sequencing Changes

Learning objectives


Action steps and tools

Learning objectives

  • Explain the "change concepts"—the changes necessary to become a medical home as defined by the Safety Net Medical Home Initiative Framework for Practice Transformation
  • Help practices test and implement changes in logical sequence



Transformation to a patient-centered medical home is a major undertaking for a practice. In order to make the change manageable, it is important to break it into steps. This module helps the practice facilitator understand the changes required to become a medical home and provides techniques and tools to help guide practices in making changes. At the heart of this framework are 8 change concepts that define the attributes of a patient-centered medical home, divided into four phases:

  • Laying the Foundation: engaged leadership and quality improvement strategy
  • Building Relationships: empanelment and continuous, team-based relationships
  • Changing Care Delivery: organized, evidence-based care and patient-centered interactions
  • Reducing Barriers to Care: enhanced access and care coordination


Action steps and tools

Action step Tool

Sequence activities based on the change concepts

SNMHI website and implementation guides
Includes an implementation guide and other tools for each change concept.

Safety Net Medical Home Initiative Self-Assessment Tool.

Change Concepts, NCQA Standards and PCMH-A Crosswalk

PCMH-A Examples Tool
Examples of translating PCMH-A scores into action. Courtesy of Pittsburgh Regional Health Initiative.

SNMHI Key Activities Checklist
Examples of key activities practices can try and adapt.

Green-Yellow-Red Assessment Tool
Coaches can use this modifiable Excel document to track and document site progress and capacity to move towards PCMH transformation on a monthly basis.

Coach’s Tiering Tool
Coaches can use this tool to assess a site’s progress and momentum toward PCMH transformation.

Emphasize laying the foundation

Missouri Community Health Centers: Strategic Considerations
Example of a presentation you can use with board members and senior management. Courtesy of Missouri Primary Care Association and Arcadia Solutions.

NACHC Leadership Development Institutes
Leadership development resource for primary care leaders from the National Association of Community Health Centers.

SFQCS Curriculum Plan
Senior Leader Learning Community Agenda & Course Outline from the San Francisco Quality Culture Series.

Video on team meetings in a clinical environment
Short video that demonstrates how team meetings can help in many situations. Produced by the California Health Care Foundation and the California Improvement Network.

Clinical Microsystems Outpatient Primary Care Greenbook
Great QI tools for helping teams learn how to lead effective team meetings.

Coach the practice to make care changes

Patient-centered interactions

Reduce barriers to care

Enhanced access


Additional Reading

Bodenheimer T. 2011. Building blocks of the patient-centered medical/health home: comment on "colorectal cancer screening among ethnically diverse, low-income patients". Arch Intern Med 171(10):912-3.

Heifetz RA et al. 2009. The practice of adaptive leadership: tools and tactics for changing your organization and the world. Boston, Mass.: Harvard Business Press.

Nutting PA, Crabtree BF, Miller WL, Stewart EE, Stange KC, Jaén CR. Journey to the Patient-Centered Medical Home: A Qualitative Analysis of the Experiences of Practices in the National Demonstration Project. Ann Fam Med. 2010;8 Suppl 1:S45-56.

Wagner EH et al. 2012. The changes involved in patient-centered medical home transformation. Prim Care 39(2):241-59.