Resources

There are many websites and publications that can help practices learn how to transform and function successfully as comprehensive care practice.  While these models have many names—medical home, comprehensive primary care, and accountable care—they share a team and patient-centered approach.  

The Agency for Healthcare Research and Quality’s Patient Centered Medical Home Resource Center includes a citations database of journal articles, reports, policy briefs, and position statements on the medical home.

The American Academy of Family Physicians offers a comprehensive collection of information and resources to assist practices in becoming Patient-Centered Medical Homes.

The American College of Physicians provides information on understanding the Patient-Centered Medical Home, including cost, benefits and incentives, and links to tools and resources.

TransforMED, an affiliate of AAFP, offers a range of Medical Home Products and Services

The National Committee for Quality Assurance’s (NCQA) Physician Practice Connections® – Patient-Centered Medical Home (PPC®-PCMH™-CMS) program builds upon NCQA’s Physician Practice Connections program to recognize primary care practices that function as patient-centered medical homes. 

The Patient-Centered Primary Care Collaborative is a coalition of employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, physicians and others who work together to develop and advance the patient-centered medical home concept.   

Medical Home News is a monthly newsletter for health care professionals interested in Patient Centered Medical Homes. Medical Home News is published by Health Policy Publishing LLC.

The National Transitions of Care Coalition has many tools, resources, and best practices for health care professionals to help enhance transitions of care. 

The Chronic Disease Self-Management Program is a key resource for providers in meeting the requirements to become a Medicare Medical Home. The National Council on Aging (NCOA) has introduced Stanford's CDSMP to 27 states. Click here for more information about CDSMP.

Project BOOST (Better Outcomes for Older adults through Safe Transitions) is a national initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home. 

The Chronic Disease Electronic Management System is an easy-to-use free registry designed to assist medical providers in managing and reporting on patients with chronic health conditions. Visit for details.

The Change Concepts support the Patient-Centered Medical Home model of care in the Safety Net Medical Home Initiative, click here for details.

Patient Education
Emmi Solutions, TransforMED and the PCPCC have partnered to create a web-based patient education tool. This engaging and educational multimedia experience helps patients understand the Patient-Centered Medical Home and their role in this collaborative health and wellness relationship with their primary care practice. Practices can place this patient education tool on a website for FREE.

The Center for the Advancement of Health developed a resource titled “Creating a Patient Guide for ‘Medical Home’ Physician Practice. Click here for details.

Other consumer resources are available on the Patient-Centered Primary Care Collaborative website

The National Transitions of Care Coalition has tools and resources for patients and families about care transitions.

"Transformation: A Family's Guide to Chronic Care, Guided Care, and Hope" by Tom Grundner, Ed.D., is a short book that describes to chronically ill patients and their families what Guided Care is and how it can help them. It is not the standard patient education book!