About Topics

Resources are filed in at least one of the following topic areas. These topics were drafted by the Institute and refined with the help of our Expert Oversight Panel and a group of Oregon technical assistance providers.

The topics provide a foundational basis for primary care home transformation; they share many similarities with the Oregon PCPCH program Core Attributes, as well as the concept areas created by other primary care home initiatives.  Core Attributes group and categorize the PCPCH standards from the perspective of patients, or why; PCPCH Standards constitute a rubric for practices to follow, or what; Topics identify the foundational basis for transformation, or how.

Although phrasing may differ, these models represent many of the same concepts.  Other initiative models include:


Patient-Centered Primary Care Institute (PCPCI) Resource Topics


About the Primary Care Home Model

Many entities offer broad information about the basics of the primary care home model, including research and evidence to support the model as a means of reducing costs while improving patient experience and obtaining better health outcomes.



Access to primary care helps people stay healthy and reduces unnecessary hospitalizations. Primary care practices can achieve better access through empanelment, panel management, focusing on continuity of care, same-day scheduling processes and strategies for providing after-hours coverage.


Behavioral Health Integration

Taking care of a person’s health includes addressing mental and emotional health alongside physical health. This often means performing screening, providing referral services and building strategic partnerships with local behavioral health organizations. But this topic also extends to fully integrating behavioral health into a practice through adding behaviorists to the health care team or co-location of physical and mental health providers.


Care Coordination

Coordinating a patient’s care between health care providers and systems can be complicated, but doing so effectively reduces waste and improves patient experience. Complex case management is aided by shared care plans, referral and specialty care coordination, transitions of care, health information exchange and community resource development. 


Comprehensive Care

Comprehensive care involves the use of evidence-based guidelines to provide prevention and screening services, chronic disease management, self-management support, medication management and more. Care should reflect the needs of the patient population, and to do this practices must know who their population is, what they need, how they are doing and how the practice is doing in meeting those needs.


Collecting & Using Data

Developing systems for collecting and using data is essential to quality improvement. Experts encourage practices to start small and grow this capability over time. This includes the selection and use of measures and working within existing data systems to produce valid, reliable and actionable reports. Data may also be used to manage patient populations, such as in the case of registry systems to track patients with certain conditions or in risk stratification. There are different types of data - including clinical, operational, access and demographic, and each provides important information for making decisions and improving quality. Once data is generated leaders look for strategies to share it and build a culture of transparency.


Leadership, Culture and Change Management

It is widely recognized that with a new model of care comes the need for new leadership skills. Leading primary care transformation involves expertise in change management; leaders must be able to create a vision, build organizational will and align transformation work with other organizational strategic goals and priorities. Leaders must also balance this work with managing revenue streams.


Patient and Family Engagement

Patients are the most important members of a health care team. Engaging patients at the visit, clinic and organizational levels is an essential, but often difficult task of primary care homes. At the visit level this includes engaging patients in understanding the primary care home and their role in their care. It also includes patient-centered communication like shared decision making.  At the clinic level engagement involves effectively partnering with patients and families in clinic improvement projects through patient surveys, episodic partnerships or forming a patient advisory council. Finally, where a larger organization exists, patients offer invaluable insight in strategic planning and other high-level planning endeavors.


Quality Improvement

Primary care homes work continuously to measure and improve the quality of care they provide to their patient population. Practice leaders should be familiar with quality improvement strategies like the Model of Improvement (Plan-Do-Study-Act) and other process improvement methods in order to adopt a quality improvement process that works best for their practice.  Tools, worksheets, diagrams and visual management techniques can help practice teams identify issues and problems and design processes and workflows.


Team-Based Care

An essential component of the primary care model is the shift away from physician/provider-centric staffing models to a team-based approach to patient care with the patient as the most critical member of their own health care team. Effective team-based care requires building the team and clarifying team roles, and managing intra-team communication.  Members of the team work “at the top of their license or certification” meaning work is spread across the team and may involve reimagining traditional roles and the responsibilities they are assigned. There are a variety of staffing models, since no one team structure will work for all. Practices vary, and teams should be based on patient populations and their needs. Team-based care also establishes the foundation for proactive management of the patient schedule through methods like scrubbing and huddling.