The Washington Academy of Family Physicians supports practice transformation initiatives and strives to provide resources for practices of all sizes and range of services. WAFP leaders and members are involved in practice transformation initiatives at state, local and regional levels, and are leading the way to deliver on the triple aim – improving the experience of care, improving the health of populations, and reducing per capita costs of health care – through innovative models and a focus on evidence based medicine and quality measures over volume.

What is the Patient-Centered Medical Home?    PCMH Graphic-2

What is the PCMH?

A patient-centered medical home (PCMH) is a model or philosophy of primary care that is patient centered, comprehensive, team based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It is a philosophy of health care delivery that encourages providers and care teams to meet patients where they are, from the most simple to the most complex conditions.


The PCMH Check List – – American Academy of Family Physicians

“Enhancing the Primary Care Team to Provide Redesigned Care:
The Roles of Practice Facilitators and Care Managers” 
Annals of Family Medicine Jan/Feb. 2013 (PDF-4 pgs)

Electronic Health Record Technology Certification

EHR Product Selection & Implementation – AAFP

– an inexpensive, simple and accurate tool which measures many of the factors that lead to achieving
the Triple Aim, with minimal effort to access.

Guidelines for Patient-Centered Medical Home Recognition and Accreditation Programs – AAFP

CMS Physician Quality Reporting System (PQRS) – AAFP registry for reporting quality measures. reporting, not pay-for-performance.

PQRS Wizard – a simple and cost-effective online tool that collects and reports quality measures data under the CMS PQRS program.

Patient & Family Engagement -Emerging Best Practice Resources and Tools
  (PDF-49 pgs)

Coordinating Care for Adults With Complex Care Needs in the Patient-Centered Medical Home: Challenges and Solution White Paper, AHRQ Jan. 2012 (PDF-61 pgs).


Achieving PCMH recognition need not be an immediate goal; there are many small, yet practical steps you can begin taking now.  Visit the following practice transformation training resources to get started:

The AAFP PCMH Planner – Step-by-Step Guide on Practice Improvement

PCMH Transformation: Getting Started – Basic Checklist    (1 pg. PDF)
PCMH Transformation: Building on Change –  Intermediate Checklist  (1 pg. PDF)
PCMH Transformation: Final Touches – Advanced Checklist  (1 pg. PDF)

Healthy Hearts Northwest/Qualis Health– a three-year project that helps primary care practices improve their patients’ cardiovascular health—while also building capacity for quality improvement.

Steps Forward, a set of free, on-line, interactive practice transformation toolkits produced by the AMA. The goal is to improve the health of patients by improving the health and well-being of physicians and their practices.

Currently there are 16 modules on topics such as

  • Practice operations: pre-visit planning, team meetings, streamlined prescription management, team documentation
  • Thematic issues: Lean, strengthening culture, reducing burnout, improving resiliency
  • ACO readiness: panel management, medication adherence
  • HIT: buying and implementing an EHR

PCMH  Success – Primary care physician groups around the country have radically reorganized healthcare in their communities and driven costs down while improving quality safety and patient experience.  Read more:

Embracing Change on the Border” – the story of Rio Grande Valley health Alliance ACO.

“High Plains Working for Health” – video tells the story of High Plains Community Health Center, a federally qualified health center that has transformed lives through improved quality of care and pathways out of poverty in rural Southeastern Colorado.

Ten Characteristics of High Value ProvidersThrough a study conducted with Stanford University, the Peterson Center for Healthcare, with Stanford University identified 10 characteristics of High Value Providers that distinguish high-performing primary care practices from others in the same community. These distinguishing features are ones that most, if not all practices can embrace