Systems of Care/Patient-Centered
Medical Home
Bibliography
I.
Health Policy
1.
Crossing The Quality Chasm: A New Health System For The 21st Century. Institute Of
Medicine. March 2001
2.
To Err Is
Human: Building a Safer Health System. Institute of
Medicine. November 1999
3.
Insights Into Health
Policy Issues: Making
Medical Homes Work: Moving From Concept To Practice.
Center For Studying Health System Change NO.
1 • Paul B. Ginsburg,
Ph.D., Myles Maxfield,
Ph.D., Ann S. O'Malley, M.D., M.P.H.,
Deborah Peikes,
Ph.D., M.P.A., Hoangmai H. Pham, M.D., M.P.H. DECEMBER
2008
4.
The
Paradox Of Primary Care. Kurt C. Stange, MD, Phd, Editor; Robert L. Ferrer, MD, MPH, Associate Editor. Ann Fam Med 2009;7:293-299.
Doi:10.1370/Afm.1023.
5.
It Takes A Region: Creating A Framework To
Improve Chronic Disease Care. Ed
Wagner, Brian Austin, And Catherine Coleman. Prepared
For: CALIFORNIA HEALTHCARE FOUNDATION”. MacColl Institute For Healthcare
Innovation. November 2006
6. Cottage Industry to Postindustrial
Care — The Revolution in Health Care Delivery. Stephen J. Swensen, M.D.,
M.M.M., Gregg S. Meyer, M.D., Eugene C. Nelson, D.Sc., M.P.H.,Gordon
C. Hunt, Jr., M.D., M.B.A., David B. Pryor, M.D., Jed I. Weissberg,
M.D., Gary S. Kaplan, M.D., Jennifer Daley, M.D., Gary R. Yates, M.D., Mark R. Chassin, M.D., M.P.P., M.P.H., Brent C. James, M.D., M.Stat., and Donald M. Berwick, M.D., M.P.P. (10.1056/NEJMp0911199) was published on
January 20, 2010, at NEJM.org.
7. Piecework, Medicine’s money problem. Atul
Gawande The New Yorker. April 4, 2005
http://www.newyorker.com/archive/2005/04/04/050404fa_fact?printable=true#ixzz0YxwHKQtR
8. Medical Professionalism in the
New Millennium: A Physician Charter. Project of the ABIM
Foundation, ACP–ASIM Foundation, and European Federation of Internal Medicine 5 February 2002 Annals of Internal
Medicine Volume 136 • Number 3 243-246
9. Donald M. Berwick. What ‘Patient-Centered’ Should Mean:
Confessions Of An Extremist: A
seasoned clinician and expert fears the loss of his
humanity if he
should become a patient.
Health Affairs 28, no. 4 (2009): w555–w565 (published online 19 May
2009; 10.1377/hlthaff.28.4.w555)]
10.
Paul
B. Ginsburg, Jon B. Christianson, Genna R. Cohen,
Allison Liebhaber.
Shifting Ground: Erosion of the Delegated Model in California. California Health Care Almanac, December
2009.
11.
The Science of Spread: How Innovations in
Care Become the Norm.
Bodenheimer, T. California HealthCare Foundation
September 2007 www.chcf.org.
12.
Grand Junction, Colorado: A Health
Community that works. Nichols, L. New America Foundation. Health Policy Program. August 2009 www.NEWAMERICA.net
13.
The Patient-Centered Medical Home
Movement- Why Now? Larson,
E. JAMA 2010;303(16):1644-45.
14.
The Political Economy of US Primary Care Sandy et al; Health Affairs, July/August 2009, pp 1136-1144.
15.
Societal Perceptions of Physicians: Knights, Knaves or Pawns,Jain et al, JAMA, 2010; 304(9): pp 1009-1010.
II.
Payment Reform
1.
Fundamental Reform of Payment for Adult
Primary Care: Comprehensive Payment for Comprehensive Care. Goroll, A.,
Berenson, R.,Schoenbaum, S.
Gardner, L. Society of General Internal Medicine. 2006
2.
Value-Driven Health Care: Proceed with
Caution. Fink,
K. J Am Board Fam
Med 2008;21:458-460.
3.
Incremental Cost Estimates For
The Patient-Centered Medical Home. October
2009 (Commonwealth Fund) Stephen
Zuckerman, Katie Merrell, Robert Berenson, David Gans,
William Underwood, Aimee Williams, Shari Erickson, And Terry Hammons
4.
A
System In Need Of Change: Restructuring
Payment Policies To Support Patient-Centered Care.
Neil Kirschner and Robert Doherty, A Position Paper of the American College
of Physicians” October
2006
5.
Redefining Competition in Health Care. Porter, M. Harvard Business Review. June
2004; 65-76
6.
Primary Care’s eroding earnings: Is
Congress concerned?
Laing, B et al. Journal of Family Practice 2008;57
(9): 578-583. www.jfponline.com.
7.
Task Force Report 6. Report on Financing the New Model of
Family Medicine. Spann, S. Ann Fam Med 2004;1-S21.DOI: 10.1370/afm.237. www.annfammed.org.
8.
Pathways for Physician Success Under Healthcare Payment and Delivery Systems. Miller, H. 2010 American Medical
Association and Center for Healthcare Quality and Payment Reform. http://www.ama-assn.org/ama1/pub/upload/mm/399/payment-pathways-summary.pdf
9.
Relationship of Clinic Medical Home Scores to Health Care
Costs.
Thomas J. Flottemesch, PhD; Patricia
Fontaine, MD, MS; Stephen E. Asche, MA; Leif I.
Solberg, MD
J Ambulatory Care Manage, Vol. 34, No. 1 pp. 78-89
10.
A Nationwide Survey of Patient Centered Medical Home Demonstration Projectsl
Asaf Bitton, MD1,2, Carina Martin, BA1, and Bruce E. Landon, MD, MBA,
MSc1,3
III.
PCMH principles
1.
Joint
Principles of the Patient-Centered Medical Home.
American
Academy Of Family Physicians (AAFP); American Academy Of Pediatrics (AAP); American College Of Physicians (ACP); American Osteopathic Association (AOA). March 2007
2.
The Patient Centered Medical Home: History, Seven Core Features, Evidence and
Transformational Change.
Robert Graham Center for Policy Studies in Family Medicine and
Primary Care.
November 2007.
3.
The Advanced Medical Home: A
Patient-Centered, Physician Guided Model of Health Care.
American College of Physicians Policy Monograph January 2006.
4.
Discussion on General Practice in a
Changing World.
Lancet June1961 v.54:443-452
5.
The Patient-Centered Medical Home
Movement – Promise and Peril for Family Medicine.
Rodgers, J. J Board Fam
Med 2008;21(5):370-374. www.jabfm.org
6.
Learning from Alta Alma: The Medical Home
and Comprehensive Primary Health Care.
Gottlieb, L. J AM Board Fam Med 2009;22:242-6. http://www.jabfm.org.
IV.
PCMH evaluation and outcomes
1.
The Medical Home: Growing Evidence to
Support a New Approach to Primary Care.
Rosentahal, T. J
Am Board Fam Med 2008;21:427-440.
2.
Initial Lessons from the First National
Demonstration Project on Practice Transformation to a Patient-Centered Medical
Home.
Nutting, P et al. Ann Fam
Med 2009;7:254-260.
Paul A. Nutting; Benjamin F. Crabtree; Elizabeth E. Stewart; William
L. Miller; Raymond F. Palmer; Kurt C. Stange; Carlos
Roberto Jaén. Annals of Family Medicine 8:S33-S44 (2010) doi:
10.1370/afm.1119. www.annfammed.org.
Paul A. Nutting; Benjamin F. Crabtree; William L. Miller; Elizabeth
E. Stewart; Kurt C. Stange; Carlos Roberto Jaén. Annals of Family Medicine 8:S45-S56 (2010) doi: 10.1370/afm.1075. www.annfammed.org.
5.
Patient Outcomes
at 26 Months in the Patient-Centered Medical Home National Demonstration
Project.
Carlos
Roberto Jaén; Robert L. Ferrer;
William L. Miller; Raymond F. Palmer; Robert Wood; Marivel
Davila; Elizabeth E. Stewart; Benjamin F. Crabtree; Paul A. Nutting;
Kurt C. Stange. Annals of Family Medicine 8:S57-S67 (2010) doi:
10.1370/afm.1121. www.annfammed.org.
Benjamin F.
Crabtree; Paul A. Nutting; William L. Miller; Kurt C.
Stange; Elizabeth E. Stewart; Carlos Roberto Jaén. Annals of Family Medicine 8:S80-S90 (2010) doi: 10.1370/afm.1107. www.annfammed.org.
7.
Context for
Understanding the National Demonstration Project and the Patient-Centered
Medical Home.
Kurt C. Stange; William L. Miller; Paul A. Nutting;
Benjamin F. Crabtree; Elizabeth E. Stewart; Carlos Roberto Jaén.
Annals
of Family Medicine 8:S80-S90 (2010) doi: 10.1370/afm.1107. www.annfammed.org.
8.
Methods for
Evaluating Practice Change Toward a Patient-Centered
Medical Home.
Carlos
Roberto Jaén; Benjamin F. Crabtree; Raymond F.
Palmer; Robert L. Ferrer; Paul A. Nutting;
William L. Miller; Elizabeth E. Stewart; Robert Wood; Marivel
Davila; Kurt C. Stange.
Elizabeth E.
Stewart; Paul A. Nutting; Benjamin F. Crabtree; Kurt
C. Stange; William L. Miller; Carlos Roberto Jaén.
Annals of Family
Medicine 8:S21-S32 (2010) doi: 10.1370/afm.1111. www.annfammed.org.
Robert J. Reid, Katie Coleman, Eric A.
Johnson, Paul A. Fishman, Clarissa Hsu, Michael P. Soman,
Claire E. Trescott, Michael Erikson, and Eric B.
Larson 10.1377/hlthaff.2010.0158
HEALTH AFFAIRS 29, NO. 5 (2010): 835–843
Patient Centered Primary Care Collaborative. August,
2009
Mark W. Friedberg, M.D., M.P.P.1,2, Dana G. Safran, Sc.D.3, Kathryn L. Coltin, M.P.H.4,
Marguerite
Dresser, M.S.5, And Eric C.
Schneider, M.D., M.Sc.
13. Reinventing
Primary Care: Lessons From Canada For The United
States.
Barbara Starfield.
10.1377/hlthaff.2010.0002
HEALTH AFFAIRS 29, NO. 5
(2010): 1030–103
Suzanne Lazorick, Md, Mph;
Virginia L. H. Crowe, Rn, Ded; Judith C. Dolins, Mph; Carole M. Lannon, Md,
MPh. Journal Of Continuing
Education In The Health Professions, 28(3):131–139, 2008
15.
Is Integration In Large Medical Groups Associated
With Quality?.
Leif I. Solberg, MD; Stephen E. Asche,
MA; Stephen M. Shortell, Phd,
MBA, MPH; Robin R. Gillies, Phd;
Nancy Taylor, MBA; L. Gregory Pawlson, MD, MPH; Sarah
Hudson Scholle, Drph, MPH; And
M. Rashell Young, MBA, MPH. (Am J Manag Care.
2009;15(6):E34-E41)
16.
The
Impact of Health Reform on Health System Spending, Issue
Brief, Center for American Progress, David M. Cutler, Karen
Davis and Kristof Stremikis. The Commonwealth Fund. May 2010
17.
Early DIAMOND adopters offer insights Six-month results on depression care. Nancy Jaeckels.
Minnesota Physician, Volume XXlll, No. 1 April 2009
18. Making
Medical Homes Work: Moving from Concept to Practice. The Center for Studying Health System Change. Policy Perspective Insights into Health Policy Issues No.
1. December 2009.
19.
The Multi-Stakeholder Movement For Primary
Care Renewal And Reform
Grundy, P, Hagan,
Hansen, and Grumbach. 10.1377/hlthaff.2010.0084 HEALTH AFFAIRS
29, NO. 5 (2010):
791–798
20.
Group Health’s Move To The Medical Home: For Doctors, It’s Often A Hard Journey Harris Meyer. 10.1377/hlthaff.2010.0345 HEALTH AFFAIRS 29, NO. 5
(2010): 844–851
21. Lessons That Patient-Centered
Medical Homes Can Learn From the Mistakes of HMOs.
Ann
M. Mirabito, PhD, and Leonard L. Berry, PhD Annals of
Internal Medicine, Ann
Intern Med. 2010;152:182-185. 2 February 2010 Annals of Internal
Medicine Volume 152 • Number 3
22.
The Medical Home: Disruptive Innovation for a New Primary Care
Model.
Deloitte Center for
Health Solutions. Health Affairs 10.1377/hlfaffw4.437. 2008
23.
Proof in Practice: A Compilation of Patient Centered Medical
Home Pilot and Demonstration Projects. Patient Centered
Primary Care Collaborative. www.pcpcc.net. 2009
24.
Are Electronic Medical Records Helpful
for Care Coordination?: Experiences of Physician Practices.
Ann S. O’Malley, MD, MPH, Joy M.
Grossman, PhD., Genna R. Cohen, BS, Nicole M. Kemper,
MPH, Hoangmai H. Pham, MD, MPH. Center for Studying Health System Change. J Gen Intern Med. Published online: 22 Dec 2009.
Boyd, C et al. J Gen Intern Med 2008
26.
Progress of Ontario's Family Health Team Model: A Patient-Centered Medical Home .
Walter W. Rosser, MD1, Jack M. Colwill, MD2, Jan Kasperski, RN, MHSc2 and Lynn Wilson, MD3,4
Annals of Family Medicine 9:165-171 (2011)
© 2011 Annals of Family Medicine, Inc.
doi: 10.1370/afm.1228
V.
PCMH Recognition Standards
1. 2011 NCQA Standards and Guidelines
®—Patient-Centered Medical Home (PPC-PCMH™). NCQA April 2009.
Http://Www.Medicalhomeimprovement.Org/Knowledge/Practices.Html#Measurement - Medical Home Index Resource Page From
The Center For Medical Home Improvement
3.
2011 NCQA Standards and Scoring
VI.
Practice Redesign
General
1.
Practice
Transformation Resources From Family Practice
Management.
www.aafp.org/online/en/home/publications/journals/fpm/collections/transformation.html
2.
A
House Is Not A Home: Keeping Patients At The Center Of Practice Redesign.
Robert A. Berenson, Terry Hammons, David N. Gans, Stephen Zuckerman, Katie Merrell, William S.
Underwood, And Aimee F. Williams. Health Affairs 27, No. 5 (2008): 1219–1230; 10.1377/ Hlthaff.27.5.1219.
3.
How to fix a Flawed Process: The Four
Rules of Practice Redesign.
Erickson,l. Family Practice Management. www.aafp.org/fpm. June 2008.
4.
What Works: Effective Tools and Case Studies To
Improve Clinical Office Practice.
Houck,S. HealthPress Publishing.
2004
5.
Primary Care
Practice Development: A Relationship-Centered Approach.
William L.
Miller; Benjamin F. Crabtree; Kurt C. Stange; Paul A.
Nutting; Carlos Roberto Jaén.
Annals of Family Medicine 8:S68-S79 (2010) doi:
10.1370/afm.1089. www.annfammed.org.
6.
The Key to Implementing Change in Your
Practice.
Johnson, B. Fam Pract Man 2008;15(8):11-13.
7.
How Can We Remodel Practices Into Medical Homes
Without a Blueprint or a Bank Account?
Leif I. Solberg, MD. J Ambulatory Care
Manage Vol. 34, No. 1, pp. 3-9
Access
1. Same Day Appointments: Exploding the Access
Paradigm.
Murray, M. Family Practice Management 2000. http://www.aafp.org/fpm/20000900/45same.html
Planned Care
1.
Escaping the Tyranny of the Urgent by Delivering
Planned Care.
Moore, L.G. Family Practice
Management May 2006 www.aafp.org/fpm.
2. Improving
Office Practice:
Working Smarter, Not Harder.
Sinsky,C.
Family Practice Management. www.aafp.org/fpm. Nov/Dec 2006.
Team Care
1.
Training Curriculum for Health Coaches.
Bodenheimer, T. UCSF Center for Excellence in Primary Care. May 2008. www.ucsf.edu/cepc.
2.
Huddles: Improve Office Efficiency in
Mere Minutes.
Stewart, Elizabeth. www.aafp.org/fpm.
Patient-Centered Care
1. Microsystems
in Health Care: Part 3. Planning Patient-Centered Services.
Marjorie M. Godfrey, MS, RN, Eugene C. Nelson, PSC, MPH, John H. Wasson, MD, Julie J. Mohr, MSPH, PhD,
Paul B. Batalden, MD. Joint
Commission on Quality & Safety Microsystem
Series. April
2003, Vol 29, Num. 4.
2.
A ‘Stages to Change’ Approach to Helping
Patients Change Behavior.
Zimmerman, G. Am Fam
Physician 2000;61:1409-16.
3.
Trends in Quality During Medical Home Transformation.
Solberg et al, Annals of Family Medicine, Vol 9, No 6, Nov/Dec 2011, pp 515-521
Information Technology
1.
Transforming Care: Medical Practice
Design and Information Technology. Kilo, C.
Health Tracking. September/October 2005.
2. Using Computerized Registries in Chronic
Disease Care.
Metzger, J, T.
California HealthCare Foundation February 2004 www.chcf.org.
Quality Improvement and Performance Management
Endsley, S.
Fam Pract
Manag. 2006 Apr;13(4):34-38
http://www.aafp.org/fpm/2006/0400/p34.html
Chronic Care
1.
Improving Primary Care for Patients with Chronic Illness. Bodenheimer, T.
,Wagner, E. JAMA 2002; 288 (14):1775-1779.
2.
Improving Primary Care for Patients with Chronic Illness: The
Chronic Care Model, Part 2. Bodenheimer, T, Wagner, E. JAMA 2002;
288 (15):1909-1914.
3. Patient Self-management of Chronic Disease in Primary Care. Bodenheimer,
T. JAMA 2002; 288 (19):2469-2472.
4. Guided Care for Multimorbid Older Adults.
Boyd, C
et al. The Gerontologist. 2007; 47 (5):697-704
5. Improving Chronic Disease in the Real World: A Step-by-Step
approach. White, B. Family
Practice Management October 1999. www.aafp.org/fpm/991000fm/38.html.
6. Helping Patients Take Charge of their Chronic Illness. Funnell, M. Family Practice Management March 2000. www.aafp.org/fpm/20000300/47help.html.
7.
Improving Chronic Illness Care: Improving
your Practice Manual. http://www.improvingchroniccare.org/index.php?p=Steps_for_Improvement&s=37
VII.
PCMH and business
1.
The Patient Centered Medical Home, A
Purchaser Guide: Understanding the Model
and Taking Action.
Patient Centered Primary Care
Collaborative. www.pcpcc.net.
2008
2.
From Our Lips To Whose
Ears? Consumer Reaction To Our Current Health Care
Dialect.
Murray
Ross, Phdtoyomi Igussophia
Gomez. “The Permanente Journal/ Winter 2009/ Volume 13 No. 1
Patricia Fontaine, MD, MS; Thomas J Flottemesch, PhD; Leif I. Solberg, MD; Stephen E. Asche, MA
J Ambulatory Care Manage, Vol. 34,
No. 1, pp. 10-19
4.
Are Patients Knights, Knaves or Pawns?,
Jain et al, JAMA, 2011; 305(20): pp 2112-2113
VIII.
Medical Neighborhood
1.
A Typology Of Specialists’ Clinical
Roles.
Forrest, C. Arch
Intern Med. 2009;169(11):1062-1068. www.Archinternmed.Com
2.
Improving
The Primary Care–Specialty Care Interface Getting From Here To There.
Alice Hm Chen, MD, MPH Hal F. Yee Jr,
MD, PhD. Reprinted Arch Intern Med/Vol 169 (No. 11), June 8, 2009 Www.Archinternmed.Com 1024
3. Specialist Physician Practices as
Patient-Centered Medical Homes
Lawrence P. Casalino, M.D.,
Ph.D., Diane R. Rittenhouse, M.D., M.P.H., Robin R. Gillies,
Ph.D., and Stephen M. Shortell, Ph.D., M.P.H.
. This
article (10.1056/NEJMp1001232) was published on April 21, 2010, at NEJM.org.
4. Information Exchange Among Physicians
Caring For The Same Patient In The Community
Carl Van Walraven
MD Msc, Monica Taljaard Phd, Chaim M. Bell MD Phd, Edward Etchells MD Msc, Kelly B. Zarnke MD, Ian G. Stiell MD Msc, Alan J. Forster MD
MSC. CMAJ
• NOVEMBER 4, 2008 • 179(10).
Mark W. Friedberg, M.D., M.P.P.1,2, Dana G. Safran, Sc.D.3, Kathryn L. Coltin, M.P.H.4,
Marguerite Dresser, M.S.5, And Eric C. Schneider, M.D., M.Sc.
6. Enhancing Continuity Of Information Essential Components
Of Consultation Reports.
Canadian Family Physician Whitney Berta Phd Jan Barnsley
Phd Jeff Bloom MD Rhonda Cockerill
Phd Dave Davis MD. Liisa Jaakkimainen MD Anne Marie Mior
Yves Talbot MD Eugene Vayda MD. • Le Médecin
De Famille Canadien Vol 55: June • Juin 2009
7.
Specialists/Subspecialists and the
Patient-Centered Medical Home.
Neil Kirschner and Michael S. Barr. CHEST. Chest 2010; 137; 200-204; Prepublished
June 8, 2009. DOI 10.1378/Chest.09-0060
8.
Primary Care, Specialist Care and Chronic
Care.
Barbara Starfield.
CHEST. Chest 2010; 137; 10-11; DOI 10.1378/Chest.09-1441.
9.
Is There Room for Specialists in the
Patient-Centered Home?
Robert A. Berenson. CHEST. Chest 2010; 137; 200-204; DOI 10.1378/Chest.09-2502.
Richard C. Anonelli,
MD, Christopher J. Stille, MD, Linda C. Freeman,
MD. Enhancing
Georgetown University
Center for Child and Human Development.
11.
Building
a Medical Neighborhood for the Medical Home.
Fisher, E. NEJM 2008. 359;12:12021205
Foy, R et al. Ann Intern Ned 2010;152:247-258
Pham, H et al. Ann Intern Med 2009;150:236-242.
IX.
Accountable Care
Organizations (ACO)
1. Fostering Accountable
Health Care: Moving Forward In Medicare.
Elliott S. Fisher, Mark B. Mcclellan, John Bertko, Steven M.
Lieberman, Julie J. Lee, Julie L. Lewis, And Jonathan S. Skinner. Health Affairs Web Exclusive 219.
DOI
10.1377/Hlthaff.28.2.W219 ©2009 Project HOPE–The People-To-People Health
Foundation, Inc.
2.
Accountable Care Organizations: Executive Briefing for Health Care
Decision-Makers.
Bruce A. Johnson, Gerald A. Niederman. Faegre & Benson. January 29, 2010.
Ken Bertka, M.D., F.A.A.F.P.; http://www.ohioafp.org/pdfs/news_publications/TOFP_Spring10.pdf
5.
A National Strategy To
Put Accountable Care Into Practice.
Mark McClellan, Aaron
N. McKethan, Julie L. Lewis, Joachim Roski, and Elliott S. Fisher. 10.1377/hlthaff.2010.0194 HEALTH AFFAIRS
29, NO. 5 (2010):
982–990
6.
Primary
Care And Accountable Care — Two Essential Elements Of
Delivery-System Reform.
Diane R. Rittenhouse, M.D., M.P.H., Stephen M. Shortell, Ph.D., M.P.H., M.B.A., And
Elliott S. Fisher, M.D., M.P.H.
7.
Case Study of a Primary Care- Based Accountable Care System
Approach to Medical home Transformation.
Robert L. Phillips, Jr. MD, MSPH; Svetlana Bronnikov,
MS; Stephen Petterson, PhD; Maribel Cifuentes, RM; Bridget Teevan,
MS; Martey Dodoo PhD;
Wilson D. Pace, MD; David R. West, PhD