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Our funding for updating this website ended in 2011, but the resources we developed are still helping clinical practices from around the world to transform the care they provide to better serve patients with chronic illness. Please visit our home page to learn more—or check out our more recent tools and resources at:


Patient-Centered Medical Home

The American Academy of Pediatrics (AAP) introduced the medical home concept in 1967, referring to a central location for archiving a child’s medical record. In its 2002 policy statement, AAP expanded the concept to refer to primary care that emphasizes timely access to medical services, enhanced communication between patients and their health care team, coordination and continuity of care, and an intensive focus on quality and safety.

In 2007, a set of seven principles describing the characteristics of a practice-based care model was issued by four physician membership organizations representing over 300,000 physicians.  The authoring organizations are:  the American Academy of Family Physicians, the American College of Physicians, the American Osteopathic Association, and AAP. The clinicians represented by these organizations provide the majority of primary care in the United States.

Background reading


The Primary Care Team Guide
Built by the MacColl Center for Health Care InnovationThe Primary Care Team Guide presents practical guidance, case studies, and numerous resources that help practices become high-functioning teams and markedly improve care. Practices are able to assess their current work flow and care team structure and make use of the Team Guide at all stages of their development. Resources include tools for managing workflow, steps for clarifying and expanding care team member roles and functions, and video tutorials. With access to the same tools and approaches used by 31 of the most effective, team-based primary care practices in the United States, practices can advance their pace to becoming PCMH certified.

TEAMcare:  Successful approach to chronic care
Group Health’s TEAMcare study shows that a collaborative approach to managing chronic disease works.  During the intervention, the nurse and patient set realistic step-by-step goals to reduce depression and blood sugar, pressure and cholesterol levels.  Each patient was coached by a nurse care manager who monitored disease control and depression, and worked with the patient’s primary care doctors to make changes in medications and lifestyle when treatment goals were not reached.

“TEAMcare is a truly patient-centered approach that enhances a primary care team to deliver optimal care for both physical and mental health in a seamless manner,” said co-author Elizabeth H.B. Lin, MD, MPH, Group Health family physician and an affiliate investigator at Group Health Research Institute. “It recognizes there can be no health without mental health."