Form 3 MHI-LV: Non-physician clinician

Appendix B:
The Medical Home Index:
Adult (Long Version)

Appendix B: MHI Tool - OMB Package Supporting Statements

Page B–1

Form Approved
OMB No. XXXX-XXXX
Exp. Date MM/DD/YYYY

Practice-Level Assessments of Processes of Care
The Medical Home Index (MHI) is a validated self-assessment and classification tool designed
to translate the broad indicators defining the medical home (accessible, family-centered,
comprehensive, coordinated, etc.) into observable, tangible behaviors and processes of care
within any office setting. It is a way of measuring and quantifying the "medical homeness" of a
primary care practice. The MHI is based on the premise that "medical home" is an evolutionary
process rather than a fully realized status for most practices. The MHI measures a practice's
progress in this developmental process.
The MHI defines, describes, and quantifies activities related to the organization and delivery of
primary care for all patients and families. All patients and families, and particularly those
affected by chronic health conditions, benefit greatly from having a high quality medical home.
Medical Home represents the standard of excellence for all primary care; this means the primary
care practice is ready and willing to provide well, acute and chronic care for all of its patients
including those affected by chronic health conditions, disabilities, or who hold other risks for
compromised health and wellness.
You will be asked to rank the level (1-4) of your practice in six domains: 1) organizational
capacity, 2) chronic condition management,3) care coordination, 4) community outreach, 5) data
management and 6) quality improvement/change. Most practices may not function at many of
the higher levels (Levels 3 and 4). However these levels represent the kinds of services and
supports which patients report that they need from their medical home. A frank assessment of
your current practice will best characterize your medical home baseline, and will help to identify
needed improvement supports.
Your responses to the MHI will help provide context for the responses patients provide on a
patient-level assessment of care coordination.
Public reporting burden for this collection of information: It is estimated that the MHI
will take 2 hours and 20 minutes to complete by a clinician and non-clinician respondent
at each participating practice filling out the instrument. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: AHRQ Reports Clearance Officer; Attention: PRA, Paperwork
Reduction Project (0935-0176); AHRQ; 540 Gaither Road, Room # 5036; Rockville, MD
20850.
Appendix B: MHI Tool - OMB Package Supporting Statements

Page B–2

The Medical Home Index: Adult
Measuring the Organization and Delivery of Primary Care for All Adults and Their Families

Clinic Contact Information
Date
Clinic Name:
Street Address:
City:
Phone:

Zip Code:

State:

Fax

Who took the lead in completing this form?
Who should we contact at your clinic if we have questions about your responses, or if responses are missing/incomplete?

Name (if different than the person who completed this form):
Title/Position/Role:
Best phone number to reach contact if different than above:
Contact E-mail:

www.medicalhomeimprovement.org
© Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

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The Medical Home Index: Adult
Measuring the Organization and Delivery of Primary Care for All Adults and Their Families

Describe your practice type/model:

Number of clinicians: MDs

Is there a care coordinator working at your practice who supports patients/families?

Yes

What is the estimated number of patients that your practice cares for?

ARNPs

PA's

Other

No
What is your patient panel size?

Can you estimate the percentage (total should = 100%) of patents that you care for who have:
1)

% Public insurance only (Medicaid/Medicare)

2)

% Private & Medicaid/Medicare

3)

% Self/No pay

4)

% Private insurance only

5)

% Other

How familiar/knowledgeable are you about the concepts of a medical home as defined by the American Academy of Pediatrics, American Academy of Family
Physicians, American College of Physicians, and American Osteopathic Association ( www.medicalhomeinfo.org; www.pcpcc.net)?
1)

No knowledge of the concepts

2)

Some knowledge/not applied

3)

Knowledgeable/concepts sometimes applied in practice

4)

Knowledgeable/concepts regularly applied in practice

How familiar/knowledgeable are you about the elements of patient-centered care?
(http://www.medicalhomeimprovement.org/pdf/National_Partnership_PCMH%20Principles_9_09.pdf)
1)

No knowledge of the concepts

2)

Some knowledge/not applied

3)

Knowledgeable/concept sometimes applied in practice

4)

Knowledgeable/concepts regularly applied in practice

(Note: Any italicized words are defined in the glossary on page 15)

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The Medical Home Index: Adult
Measuring the Organization and Delivery of Primary Care for All Adults and Their Families
INSTRUCTIONS:
This instrument is organized under six domains:
1) Organizational Capacity 2) Chronic Condition Management

3) Care Coordination

4) Community Outreach
6) Quality Improvement
5) Data Management
Each domain has anywhere from 2 -7 themes, these themes are represented with progressively comprehensive care processes and are expressed as a
continuum from Level 1 through Level 4. For each theme please do the following:
First:
Read each theme across its progressive continuum from Levels 1 to Level 4.
Second:
Select the LEVEL (1, 2, 3 or 4) which best describes how your practice currently provides care for patients with chronic health
condition
Third:
When you have selected your Level, please indicate whether practice performance within that level is:
"PARTIAL"
(some activity within level) or "COMPLETE" (all activity within that level).
For the example below, "Domain 1: Organizational Capacity, Theme 1. 1 "The Mission..." the score for the practice is: "Level 3",
"PARTIAL".

EXAMPLE

Domain 1: Organizational Capacity:
THEME:

Level 1

Level 2

#1.1
The
Mission
of the
Practice

Primary care providers (PCPs) at
the practice have individual ways
of delivering care to patients
with chronic health conditions;
their own education, experiences
and interests drive care quality.

Approaches to the care of patients
with chronic health conditions at
the practice are more disease than
patient-centered; office needs drive
the implementation of care (e.g.
carrying out processes of care).

PARTIAL
©

COMPLETE

PARTIAL

Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

COMPLETE

Level 3
The practice uses a patient and
family-centered approach to
care, staff assess patients with
chronic health conditions and
the needs of their families in
accordance with their practice
mission; feedback is solicited
from patients and families/
caregivers and influences office
policies (e.g. the way things are
done).
X PARTIAL

COMPLETE

Level 4
In addition to Level 3, a patient/
consumer "advisory group" promotes
patient-centered strategies, practices, and
policies (e.g. enhanced communication
methods or systematic inquiry of
patient concerns/priorities); a written,
visible mission statement reflects
practice commitment to quality care for
all patients and their families.

PARTIAL
The Medical Home Index - Page

COMPLETE
4

Domain 1: Organizational Capacity:
THEME:
#1.1
The Mission of
the Practice

Level 1

Level 2

Level 3

Level 4

Primary care providers (PCPs) at
the practice have individual ways
of delivering care to patients
with chronic health conditions;
their own education, experiences
and interests drive care quality.

Approaches to the care of patients
with chronic health conditions at
the practice are more disease than
patient-centered; office needs drive
the implementation of care (e.g.
carrying out processes of care).

The practice uses a patient and familycentered approach to care, staff assess
patients with chronic health
conditions and the needs of their
families in accordance with their
practice mission; feedback is solicited
from patients and families/caregivers
and influences office policies (e.g. the
way things are done).

In addition to Level 3, a patient/
consumer "advisory group" promotes
patient-centered strategies, practices, and
policies (e.g. enhanced communication
methods or systematic inquiry of
patient concerns/priorities); a written,
visible mission statement reflects
practice commitment to quality care for
all patients and their families.

PARTIAL

COMPLETE

#1.2
Communication between the
Communication patient and the PCP occurs as a
result of patient inquiry; PCP
/Access

contacts with the patient are for
test result delivery or planned
medical follow-up.

PARTIAL

COMPLETE

#1.3
A policy of access to medical
records is not routinely discussed
Access to the
Medical Record with patients; records are
Requires both MD &
key non-MD staff
person's perspective.

provided only upon request.

PARTIAL

COMPLETE

PARTIAL

COMPLETE

In addition to Level 1,
standardized office
communication methods are
identified to the patient by the
practice (e.g. call-in hours,
phone triage for questions, or
provider call back hours).

PARTIAL

COMPLETE

In addition to Level 1, it is
established among staff that
patients can review their own
record (but this fact is not
explicitly shared with patients).

PARTIAL

COMPLETE

PARTIAL

PARTIAL

COMPLETE

Practice and patient communicate at
agreed upon intervals and both agree
on "best time and way to contact
me"; individual needs prompt weekend or other special appointments.

PARTIAL

PARTIAL

In addition to Level 3, office activities
encourage individual requests for
flexible access; access and
communication preferences are
documented in the care plan and web
messages, home, work or used by other
practice staff (e.g. fax, e-mail or
residential care visits).
PARTIAL

COMPLETE

All patients are informed that they
have access to their record; staff
facilitates access within 24-48 hours.

COMPLETE

COMPLETE

In addition to Level 3, practice
orientation materials include
information on record access; staff
locates space for patients to read their
records and make themselves available
to answer questions.
PARTIAL

COMPLETE

COMPLETE

Instructions: A) Please select and circle one level from Levels 1, 2, 3, or 4 for each theme above (circle one).
B) Then indicate whether you place your practice at a PARTIAL or COMPLETE ranking within that level (circle one).

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Domain 1: Organizational Capacity (continued):
THEME:

Level 1

#1.4
Office
Environment

Special needs concerning physical
access and other visit
accommodations are considered
at the time of the appointment
and are met if possible.

Requires both MD
& key non-MD
staff person's
perspective.

PARTIAL

#1.5
Patient/Family
Feedback
Requires both MD
& key non-MD
staff person's
perspective.

Patient feedback to the practice
occurs through external
mechanisms such as satisfaction
surveys issued by a health plan;
this information is not always
shared with practice staff.

PARTIAL

#1.6
Cultural
Competence

COMPLETE

Primary care provider (PCP)
attempts to overcome obstacles
of language, literacy, or personal
preferences on a case by case
basis when confronted with
barriers to care.

PARTIAL

©

COMPLETE

COMPLETE

Level 2
Assessments are made during the
visit of patients with chronic
health conditions; any physical
access & other visit
accommodation needs are
addressed at the visit and are
documented for future
encounters.

PARTIAL

COMPLETE

Feedback from patients with
chronic health conditions is
elicited sporadically by individual
practice providers or by a suggestion
box; this feedback is shared
informally with other providers and
staff.

PARTIAL

COMPLETE

In addition to Level 1, resources
and information are available for
patients with chronic health
conditions of the most common
cultural backgrounds; others are
assisted individually through efforts
to obtain translators or to access
information from outside sources.
PARTIAL

Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

COMPLETE

Level 3

Level 4

In addition to Level 2, staff ask
about any new or pre-existing
physical and social needs when
scheduling appointments, chart
documentation is updated and staff
are informed/prepared ahead of time
ensuring continuity of care.

In addition to Level 3, key staff identify
patients scheduled each day with chronic
health conditions, prepare for their visit
and assess and document new needs at
the visit; an office care coordinator
prepares both office staff and the office
environment for the visit; s/he advocates
for changes (office/environmental) as
needed.

PARTIAL

PARTIAL

COMPLETE

Feedback from patients with chronic
health conditions regarding their
perception/experience of care is
gathered through systematic methods
(e.g. surveys, focus groups, or
interviews); there is a process for staff
to review this feedback and to begin
problem solving.
PARTIAL

In addition to Level 2, translation
services and materials are available and
appropriate for non-English speaking
patients with chronic health
conditions and/or those with limited
literacy; these materials are appropriate
to the reading level of the patient and
their family or caregiver.
PARTIAL

COMPLETE

In addition to Level 3, an advisory
process is in place for patients with
chronic health conditions which helps to
identify needs and implement creative
solutions; there are tangible supports to
enable patients and families/caregivers to
participate in this process (e.g. after hours
events, transportation, stipends, etc).
PARTIAL

COMPLETE

COMPLETE

COMPLETE

In addition to Level 3, patient
assessments include pertinent cultural
information, particularly about health
beliefs; this information is incorporated
into care plans; the practice uses these
encounters to assess patient and
community cultural needs.
PARTIAL

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Domain 1: Organizational Capacity (continued):
THEME:
#1.7
Staff Education
Requires both MD &
key non-MD staff
person's perspective.

Level 1

Level 2

For all staff, an orientation to
In addition to Level 1, the practice
internal office practices, procedures supports (paid time/tuition
and policies is provided.
support) continuing education for
all staff in quality care for patients
with chronic health conditions.

PARTIAL

COMPLETE

PARTIAL

COMPLETE

Level 3

Level 4

In addition to Level 2, educational
information on community-based
resources for patients with chronic
health conditions, including diagnosis
specific resource information, is
available for all staff.

PARTIAL

COMPLETE

In addition to Level 3, patients with
chronic health conditions are integrated
into office staff orientations and
educational opportunities as teachers or
"patient faculty"; tangible supports for
patients and families and caregivers are
provided to enable them to take on this
role.
PARTIAL
COMPLETE

Domain 2: Chronic Condition Management (CCM) :
THEME:
#2.1
Identification of
Populations of
Patients with
Chronic Health
Conditions
#2.2
Care Continuity

Level 1

Level 2

Patients with chronic health
conditions can be counted
informally (e.g. by memory or
from recent acute encounter);
comprehensive identification
can be done through individual
chart review only.

Lists of patients with chronic
health conditions are extracted
electronically by diagnostic code.

PARTIAL
COMPLETE
Visits occur with the patients’
own primary care provider
(PCP) for annual preventive
visits or as a result of acute
problems; the patient determines
when follow up occurs.

PARTIAL
COMPLETE
Non-acute visits occur with
patients and their PCP to address
chronic condition care; the PCP
determines appropriate visit
intervals; follow-up includes
communication of tasks to staff
and of lab and medical test results
to the patient.

PARTIAL

©

COMPLETE

PARTIAL

Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

COMPLETE

Level 3

Level 4

A population of patients with chronic
health conditions is generated by
using a set group of diagnoses; the list
is used to enhance care and/or define
practice activities (e.g. to flag charts and
computer databases for special
attention or identify a population and
its subgroups)
PARTIAL
COMPLETE
The team (PCP, patient, and staff)
develops a plan of care following
evidence-based practices for patients
with chronic health conditions, the
plan details visit schedules and
communication strategies; home,
work and community concerns are
addressed in this plan and cross
coverage providers are so informed.
PARTIAL
COMPLETE

In addition to Level 3, patients with
chronic health conditions are identified
and documented, problem lists are
current, and complexity levels are
assigned to each patient; this
information creates an accessible practice
database/patient registry.
PARTIAL
COMPLETE
In addition to Level 3, the practice /teams
use chronic condition protocols which
include goals, services, interventions and
referral contacts. A designated care
coordinator uses these tools and other
standardized office processes to support
and engage patients and their families
and/or caregivers.
PARTIAL

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Domain 2: Chronic Condition Management (continued):
THEME:
#2.3
Continuity
Across Settings

Level 1

Level 2

Level 3

Communication among the
PCP, specialists, therapists, and
health care agencies happen as
needs arise for patients with
chronic health conditions.

A PCP makes requests and/or
responds to requests from
agencies or employers on behalf
of patients with chronic health
conditions (e.g. specific needs for
accommodations, medical orders
or approval of plans, or for a
particular workplace support); all
communication is documented.

Systematic practice activities foster
communication among the practice,
patient, and external providers such as
specialists, therapists, and other
community professionals supporting
patients with chronic health
conditions in their self-management;
these methods are documented and
may include e-mail, conference calls,
information exchange forms, or ad
hoc meetings with external providers.

PARTIAL

#2.4
Cooperative
Management
Between
Primary Care
Provider
(PCP) and
Specialists

COMPLETE

Specialty referrals occur in
response to specific diagnostic
and therapeutic needs; patients
are the main initiators of
communication between
specialists and their primary care
provider (PCP).

PARTIAL

COMPLETE

PARTIAL

COMPLETE

In addition to Level 1, specialty
referrals use phone, written and/or
electronic communications; the
PCP waits for or relies upon the
specialists to communicate back
their recommendations.

PARTIAL

COMPLETE

PARTIAL

Level 4

PARTIAL

COMPLETE

The PCP and patient set goals for
referrals and communicate these to
specialists; together they clarify
comanagement roles among patient,
PCP and specialists and determine
how specialty feedback to the patient
and PCP supports self management
and is explicitly shared.

PARTIAL

In addition to Level 3, a method is used
to convene the patient (and family/
caregiver as appropriate) and key
professionals on behalf of patients with
chronic health conditions; specific issues
are brought to this group and they all
share and use a written plan of care.

COMPLETE

In addition to Level 3, the patient has
the option of using the practice in a
strong coordinating role; patients as
partners with the practice manage their
care using specialists for consultations
and information (unless they decide it
is prudent for the specialist to manage
the majority of their care).

PARTIAL

COMPLETE

COMPLETE

Instructions: A) Please select and circle one level from Levels 1, 2, 3, or 4 for each theme above (circle one).
B) Then indicate whether you place your practice at a PARTIAL or COMPLETE ranking within that level (circle one).

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Domain 2: Chronic Condition Management (continued):
THEME:

Level 1

Level 2 (in addition to level 1)

The practice learns of any
emergency room use,
hospitalizations, rehabilitation
care, or other access to and
to hospital; hospital to transition points along the health
hospital; hospital to
care continuum-after they occur
home, nursing home, through discharge summaries or
or rehab; from ER to directly from patients at
primary care or home; subsequent office visits.
from one primary care
setting to another,
etc).

#2.5
Transitions of
care: (From home

PARTIAL

#2.6
Patient/Family
Support
Requires both MD
& key non-MD staff
person's perspective.

Patients are responsible for
carrying out recommendations
made to them by their PCP
when they specifically ask for
support or help.

PARTIAL

©

COMPLETE

COMPLETE

The practice provides patients who
have chronic health conditions
with explicit information and
tools (e.g. fax back forms or
information about the role of their
primary care medical home); the
patient is solely responsible for
timely communications about
transitions back to primary care.

PARTIAL

COMPLETE

The practice responds to the
clinical needs of the patient;
broader social and family needs
are addressed and referrals to
support services facilitated.

PARTIAL

Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

COMPLETE

Level 3

(in addition to level 2)

Patients with chronic health
conditions have a portable written
plan of care which includes practice
contact information and a request for
timely updates about any care
transitions. The practice-based care
coordinator communicates with
hospital and rehabilitation discharge
planners and referring clinics prior to
transitions to insure needed resources
are in place and follow-up plans are
clear.
PARTIAL

COMPLETE

(in addition to level 2)

In addition to Level 3:
Electronic health information systems
are in place to identify and receive real
time information about patient access to
the health care system and related
transitions of care; the practice team
receives timely transfer of patient
information and integrates this
knowledge into a full and continuous
plan of care (in partnership with the
patient and family or care giver).
PARTIAL

COMPLETE

The practice actively takes into account
the overall impact when an individual
has a chronic health condition by
considering all family members in care;
when patients make requests, staff will
assist them to set up supportive
connections.

PARTIAL

Level 4

COMPLETE

In addition to Level 3, the practice
sponsors patient support and self
management activities (e.g. group
appointments, condition related support
groups, and patient education); staff
have current knowledge of community
or state support organizations and work
with patients/families to make
connections.
PARTIAL

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Domain 3: Care Coordination:
THEME:
#3.1
Care
Coordination
/Role
Definition

Level 1
Patients coordinate their care
without specific support; they
integrate office
recommendations into care.

PARTIAL

#3.2
Patient/Family
Involvement

The PCP makes medical
recommendations and defines
care coordination needs, the
patient carries these out.

PARTIAL

#3.3
Patient
Family/
Caregiver
Education
Requires both MD
& key non-MD
staff person's
perspective.

©

COMPLETE

COMPLETE

Generic and specific reading
materials and brochures are
available from the practice upon
request.

PARTIAL

COMPLETE

Level 2

Level 3

Level 4

The primary care provider (PCP)
or a staff member engages in care
support activities as needed;
involvement with the patient is
variable.

Care coordination activities are
based upon ongoing assessments of
patient/family needs; the practice
partners with the patient to
accomplish care coordination goals.

Practice staff offers a set of care
coordination activities (*see page 16),
their level of involvement fluctuates
according to patient wishes. A
designated care coordinator ensures the
availability of these activities including
written care plans with ongoing
monitoring.

PARTIAL

COMPLETE

Patients are regularly asked what
care supports they need;
treatment decisions are made
jointly with their PCP .

PARTIAL

COMPLETE

Basic information relevant to
patients with chronic health
conditions is offered in one on
one interactions; these encounters
use supportive written condition
and resource information.

PARTIAL

Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

COMPLETE

PARTIAL

COMPLETE

In addition to Level 2, patients (and
families/caregivers) are given the
option of centralizing care
coordination activities at and in
partnership with the practice.

PARTIAL

COMPLETE

General information regarding
managing one’s chronic health
condition and evidence-based
diagnosis specific information is
offered by the practice in a
standardized manner; education
anticipates potential issues and
problems and refers patients to
additional educational resources.
PARTIAL

COMPLETE

PARTIAL

COMPLETE

In addition to Level 3, patients/families
contribute to a description of needed
care coordination activities; a care
coordinator specifically develops and
implements this practice capacity which is
evaluated by patients and families and
designated supervisors.
PARTIAL

COMPLETE

In addition to Level 3, diverse materials
and teaching methods are used to
address individual learning styles and
needs; education is broad in scope and
learning outcomes are measured.

PARTIAL

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Domain 3: Care Coordination (continued):
THEME:

Level 1

#3.4
Assessment
of Needs/
Plans of
Care

Presentation of patients with
acute problems determines how
needs are addressed.

PARTIAL

#3.5
Resource
Information
and Referrals
Requires both MD
& key non-MD
staff person's
perspective.

Information about resource
needs and insurance coverage is
gathered during regular patient
visit intakes; the practice addresses
immediate patient information
and resource needs.

PARTIAL

#3.6
Advocacy

COMPLETE

The PCP suggests that the
patient find support services &
resources outside of the practice
when specific needs arise (e.g.
diagnosis specific support groups,
disability rights organizations, or
patient support centers).

PARTIAL

©

COMPLETE

COMPLETE

Level 2
PCPs identify specific needs of
patients; follow-up tasks are
arranged for or are assigned to
available staff.

PARTIAL

COMPLETE

Using a listing of community,
state, and national resources which
cover physical, developmental,
social and financial needs the
practice responds to patient requests
for information; the patient seeks
out additional information & may
share lessons learned with the
practice.
PARTIAL

COMPLETE

All patients/families/caregivers
are routinely provided with basic
information about patient and
family support groups and
advocacy resources during
scheduled practice visits.

PARTIAL

Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

COMPLETE

Level 3

Level 4

Patients with a chronic health
condition, family, and PCP review
current health status and anticipated
problems or needs; they create/revise
action plans and allocate shared
responsibilities at least 2 times per
year or at individualized intervals.
PARTIAL

PARTIAL

COMPLETE

Significant office knowledge about
medical resources and insurance
options is available; assessment of
patient needs leads to supported use
of resources and information to solve
specific problems.

PARTIAL

COMPLETE

The practice team identifies
resources to the patient for support
and advocacy, facilitates the
connections, and advocates on a
patient’s behalf to solve specific
problems pertinent to their
conditions and needs.

PARTIAL

COMPLETE

In addition to Level 3, the PCP/staff
and patients create a written plan of care
that is monitored at every visit; the
office care coordinator is available to the
patients and family to implement,
update and evaluate the care plan.
COMPLETE

In addition to Level 3, practice staff work
with patients helping to solve resource
problems; a designated care coordinator
provides follow up, researches additional
information, seeks and provides
feedback and assists the patient to
integrate new information into their
care plans.

PARTIAL

COMPLETE

In addition to Level 3, the team
advocates on behalf of all patients with
chronic health conditions and their
families as a population and helps to
create opportunities for community
forums, discussions or support groups
which address specific health and
wellness concerns.
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Domain 4: Community Outreach:
THEME:
#4.1
Community
Assessment of
Health Needs

Level 1
Primary care provider (PCP)
awareness of the population of
patients with chronic health
conditions in their community is
directly related to the number of
patients for whom the provider
cares.

PARTIAL

#4.2
Outreach to
Community
Based Agencies

COMPLETE

When the patient, family,
employer or agency request
interactions with the primary
care provider (PCP) on behalf of
a patient’s community needs, the
provider responds, thereby
establishing the practice as a
resource.

PARTIAL

COMPLETE

Level 2

Level 3

Level 4

The practice learns about issues and
needs related to patients with
chronic health conditions from
key community informants;
providers blend this input with
their own personal observations to
make an informal and personal
assessment of the needs of patients
in their community.
PARTIAL
COMPLETE

In addition to Level 2, providers raise
their own questions regarding the
population of patients with chronic
health condition in their practice
communities; they seek pertinent data
and information from patients and
local/state sources and use data to
inform practice care activities.

In addition to Level 1, when a
community agency or employer
requests technical assistance or
education from the practice about
patients with chronic health
conditions, the practice
communicates, collaborates, and
educates based upon availability
and interest.

The practice initiates outreach to
community agencies and employers
that directly serve patients with
chronic health conditions (e.g.
through representation on one or
more advisory boards or committees);
the practice advocates for preventive
care and self management support
with inter-organizational collaboration
and communication.

PARTIAL

COMPLETE

PARTIAL

PARTIAL

PARTIAL

COMPLETE

COMPLETE

In addition to Level 3, at least one
clinical practice provider participates in a
community-based public health needs
assessment about patients with chronic
health conditions, integrates results into
practice policies, and shares conclusions
about population needs with
community & state agencies.
COMPLETE

In addition to Level 3, the practice
identifies needs of patients and their
families; they work with patients to
sponsor activities that raise community
awareness of resource and support
needs (e.g. home care, respite,
exercise/fitness and recreation
opportunities, or improving home,
provider, and employer
communications).
PARTIAL

COMPLETE

Instructions: A) Please select and circle one level from Levels 1, 2, 3, or 4 for each theme above (circle one).
B) Then indicate whether you place your practice at a PARTIAL or COMPLETE ranking within that level (circle one).

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Domain 5: Data Management:
THEME:
#5.1
Electronic
Data Support

Level 1

Level 2

Level 3

Level 4

Primary care providers (PCPs)
retrieve information/data by
individual chart review;
electronic data are available and
retrievable from payer sources
only.

Electronic recording of data is
limited to billing & scheduling;
data are retrieved according to
diagnostic codes in relation to
billing and scheduling; these data
are used to identify specific
patient groupings.

An electronic data system includes
identifiers and utilization data about
patients with chronic health
conditions; these data are used for
monitoring, tracking, and for
indicating levels of care complexity.

In addition to Level 3, an electronic
data system is used to support the
documentation of need, monitoring of
clinical care, following of evidencebased practices, care plan development
and related coordination and the
determination of outcomes (e.g.
clinical, functional, satisfaction and cost
outcomes).

PARTIAL

#5.2
Data Retrieval
Capacity

PCP retrieves patient data from
paper records in response to
outside agency requirements
(e.g. quality standards, special
projects, or practice
improvements).

PARTIAL

©

COMPLETE

COMPLETE

PARTIAL

COMPLETE

The practice retrieves data from
paper records and electronic
billing and scheduling for the
support of significant office
changes (e.g. staffing, or
allocation of resources).

PARTIAL

Center for Medical Home Improvement (CMHI), MHI Adult Version 1.1, 2008

COMPLETE

PARTIAL

COMPLETE

Data are retrieved from electronic
records to identify and quantify
populations and to track selected
health indicators & outcomes.

PARTIAL

COMPLETE

PARTIAL

COMPLETE

In addition to Level 3, electronic
reports are produced and used to drive
practice improvements and to measure
quality against benchmarks; (those
producing and using data practice patient
confidentiality).

PARTIAL

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COMPLETE

13

Domain 6: Quality Improvement/Change:
THEME:
#6.1
Quality
Standards
(structures)

Level 1
Quality standards for patients
with chronic health conditions
are imposed upon the practice by
internal or external organizations.

PARTIAL

#6.2
Quality
Activities
(processes)

COMPLETE

Primary care providers (PCPs) have
completed courses or have had
an adequate orientation to
continuous quality improvement
methods.

PARTIAL

COMPLETE

Level 2
In addition to Level 1, an
individual staff member
participates on a practice committee
for improving processes of care
for patients with chronic health
conditions. This person
communicates and promotes
improvement goals to the entire
practice.
PARTIAL

COMPLETE

Corporate owners, administrators
or payers identify practice deficits
and set goals for improvements;
practice providers and staff are
identified to fix problems without
having prior/or limited
participation in the process.

PARTIAL

COMPLETE

Level 3

Level 4

The practice has its own systematic
quality improvement structures for
patients with chronic health
conditions; regular provider and staff
meetings are used for input and
discussions on how to improve care
and treatment for these populations
of patients.

In addition to Level 3, the practice
actively utilizes quality improvement
(QI) processes; staff and patients are
supported to participate in these QI
activities; resulting quality standards are
integrated into the operations of the
practice.

PARTIAL

COMPLETE

Periodic formal and informal quality
improvement activities gather staff
input about practice improvement
ideas and opportunities for patients
with chronic health conditions;
efforts are made toward related
changes and improvements for this
population.
PARTIAL

PARTIAL

COMPLETE

In addition to Level 3, the practice
systematically learns about patients with
chronic health conditions and draws
upon patient, family and caregiver
input; together the practice and patient
design and implement office changes
that address needs and gaps; they then
study outcomes and act accordingly.
PARTIAL

COMPLETE

COMPLETE

Please make certain you have chosen a Level (1-4).
Also indicate whether your practice performance within that level is "partial" (some activity within that level) or "complete" (all activity within the level). Thank You

Instructions:
A) Please select and circle one level from Levels 1, 2, 3, or 4 for each theme above (circle one).
B) Then indicate whether you place your practice at a PARTIAL or COMPLETE ranking within that level (circle one).

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The Medical Home Index: Adult
Measuring the Organization and Delivery of Primary Care for All Adults and Their Families
Definitions and Concepts

(Words in italics throughout the document are defined below).

Medical Home
A medical home is a community-based primary care setting which provides and coordinates high quality, planned, patient/family-centered: health
promotion (acute, preventive) and chronic condition management (© CMHI, 2006).
Achieving a high quality medical home requires:
a) macrosystem support for infrastructure (health systems policy level) and
b) microsystem support for (primary care) practice improvement

Joint Principles of the Patient Centered Primary Care Medical Home
Use this link ( http://www.pcpcc.net/ ) to go to the Patient Centered Primary Care Collaborative website to download the consensus document: The
Joint Principles of the Patient Centered Medical Home (click on patient centered medical home ), endorsed by:
The American Academy of Family Physicians (AAFP)
The American Academy of Pediatrics (AAP)
The American College of Physicians (ACP), and
The American Osteopathic Association (AOA)

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The Medical Home Index: Adult
Measuring the Organization and Delivery of Primary Care for All Adults and Their Families
Glossary of Terms
Practice-Based Care Coordination
Care and services performed in partnership with the patient, family, & caregiver by health professionals to:
1) Establish patient-centered community-based "Medical Homes" for patients with chronic health conditions and their families.
-Make assessments and monitor needs
-Participate in patient/professional practice improvement activities
2) Facilitate timely access to the Primary Care Provider ( PCP ), services and resources
-Offer supportive services including counseling, education and listening
-Facilitate communication among PCP, patients and others
3) Build bridges among patients and health, education, social services and employer; promotes continuity of care
-Develop, monitor, update and follow-up with care planning and care plans
-Organize team meetings; support meeting recommendations and follow-up
4) Supply/provide access to referrals, information and education for patients and caregivers across systems.
-Coordinate inter-organizationally
-Advocate with and for the patient and family (e.g. at work or with health care settings)
5) Maximize effective, efficient, and innovative use of existing resources
-Find, coordinate and promote effective and efficient use of current resources
-Monitor outcomes for patient and practice

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The Medical Home Index: Adult
Measuring the Organization and Delivery of Primary Care for All Adults and Their Families
Glossary of Terms

* (continued)

Chronic Condition Management (CCM):
CCM involves explicit changes in the roles of providers and office staff aimed at improving:
1) Access to needed services
2) Communication with specialists, employers, and other resource supports, and
3) Outcomes for patients, families, practices, employers and payers.
Quality:
Quality is best determined or judged by those who need or who use the services being offered. Quality in the medical home is best achieved when
one learns what patients with chronic health conditions need and their families require for care and what they need for support. Health care teams in
partnership with patients then work together in ways which enhance the capacity of the patient and the practice to meet these needs. Responsive care is
designed in ways which incorporate patients needs and suggestions. Those making practice improvements must hold a commitment to doing what
needs to be done and agree to accomplish these goals in essential partnerships with patients.
Office Policies:
Definite courses of action adopted for expediency; "the way we do things"; these are clearly articulated to and understood by all who work in the
office environment.
Patient–centered care:
Patient-centered, defined by the Institute of Medicine, is providing care that is respectful of and responsive to individual patient preferences, needs
and values and ensuring that patient values guide all clinical decisions.
Family-Centered care:
Recognizes that the family is essential to the patient/child's care and is constant in the patient/child's life.
The medical provider acknowledges who the key family members are
The medical provider asks families what they value
Decision-making is shared
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The Medical Home Index: Adult
Measuring the Organization and Delivery of Primary Care for All Adults and Their Families
GLOSSARY OF TERMS * (continued)
Practice:
The place, providers, and staff where the PCP offers care
Primary Care Provider (PCP):
Physician or nurse practitioner who is considered the main provider of health care for the patient
Requires both MD and key non-MD staff person's perspective - you will see this declaration before select themes; CMHI has determined that
these questions require the input of both MD and non MD staff to best capture practice activity.
Notes, comments and questions:

Comments:

Questions:

Confusing themes:
What do you want to be asked that this measurement tool does not address?
What would you like us to know about the quality of care that you provide?
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