The Blueprint

PCMHs distinguished by population management activity

by Amanda Berra

A key marker for an effective patient-centered medical home (PCMH) is the extent to which population management activities become a central part of day-to-day workflow. Advisory Board research finds that today’s medical homes are engaged in significantly more population-management activity than non-medical home primary care practices.

How is a medical home really different from conventional primary care?

Defining and measuring the effect of medical homes has become an industry within an industry in health care. A full treatment of the topic has to encompass competing accreditation standards, an ongoing quest for definitive outcomes metrics, a scarcity of statistically generalizable impact data, and more.

However, it is actually fairly simple to identify a functional medical home in the real world. The trick is to look at which activities are actually taking place every day. Key example: Are key population management tasks embedded into day-to-day workflow—or not?

Cutting through the complexity:  Focusing on population management

At a substantive medical home site, significant staff time and resources are dedicated to activities that support population management goals, including:   

  • Patient self-management support: Offering patients ongoing health coaching, education, and help with goal-setting
  • Data-driven population management: Entering and mining patient data for health care improvement opportunities
  • Pre-visit planning: Reviewing patient charts prior to visit to identify missed or upcoming health care needs

Is it happening? A look at the data

At this early point in adoption of the model, many PCMH sites are still works in progress. But even so, the Medical Home Project’s 2011 Primary Care/Medical Home Benchmarking Initiative found that self-identified medical homes are already significantly more likely to offer key population management services compared to non-medical homes in the sample.   

Population management services/activities per site

N=70 medical homes, 66 non-medical homes

Population Management Activity    



   Patient Self-Management Support



   Population Management Data Entry



   Population Management Data Analysis



   Pre-Visit Planning



Next up: Medical home staff model

In addition to looking at which population management activities take place, the Medical Home Project has amassed a tremendous amount of information on the staff model used to support these workstreams. This includes not just how many FTEs with what clinical credentials are working in these practices, but also whether and how  “top of license” principles are being applied a medical home sites. In other words, are lower-level clinical credentialed staff playing more robust roles in the practice, and offloading some of the work from other team members (such as physicians) so as to extend the reach and quality performance of the practice?

Without delving too deeply into the topic here, the short answer is that in both quantitative and qualitative research, we see extensive innovation under way among medical home staff models. Medical home organizations are taking concrete steps to make lower-clinical credential jobs as robust as possible, freeing up higher clinical credential positions to take on more complex care and improving both the quality and the productivity of the practice.
For example, the benchmarking survey asked respondents “Who is the primary owner of pre-visit planning?”  At 27% of non-medical home sites, a physician owned this job—compared to only 12% of medical home sites. 

More detail to come in the next post (please subscribe to the blog to receive new blog alerts).

Related resources

Amanda Berra