communicating with patients. element 1b—access and communication results the practice has data showing that it meets the standards in element 1a for scheduling and communicating with patients. element 2d—organizing clinical data the practice uses electronic or paper-based charting tools to organize and document clinical information. element 2e—identifying important conditions the practice uses an electronic or paper-based system to identify the following in the practice's patient population: most frequently seen diagnoses most important risk factors three clinically important conditions element 3a—guidelines for important conditions the practice must implement evidence-based guidelines for the three identified clinically important conditions. element 4b—self management support the practice works to facilitate self-management of care for patients with one of the three clinically important conditions. element 6a—test tracking and follow-up the practice works to improve effectiveness of care by managing the timely receipt of information on all tests and results. element 7a—referral tracking the practice seeks to improve effectiveness, timeliness and coordination of care by following through on critical consultations with other practitioners. element 8a—measures of performance the practice measures or receives performance data by physician or across the practice regarding: clinical process clinical outcomes service data patient safety element 8c—reporting to physicians the practice reports on its performance on the factors in elements 8a. scientific evidence recent peer-reviewed literature that examines the prevalence and effectiveness of medical homes includes: in 2007, researchers from the centers for disease control and prevention published a study involving interviews with 5400 parents; the authors concluded that continuous primary care in a medical home was associated with higher rates of vaccinations for the respondents' children. schoen and colleagues (2007) surveyed adults in seven countries, using the answers to four questions to categorize the respondents as having a medical home or not. having a medical home was associated with less difficulty accessing care after hours, improved flow of information across providers, a positive opinion about health care, fewer duplicate tests, and lower rates of medical errors. a review of 33 articles by homer et al. on medical homes for children with special health care needs published in 2008 "provide moderate support for the hypothesis that medical homes provide improved health-related outcomes." a 2008 review by rosenthal determined that peer-reviewed studies show "improved quality, reduced errors, and increased satisfaction when patients identify with a primary care medical home." in a survey of parents or legal guardians of children with special health care needs published in 2009, 47.1% of the children had a medical home, and the children with a medical home had "less delayed or forgone care and significantly fewer unmet needs for health care and family support services" than the children without a medical home. reid et al. (2010) showed within the group health system in seattle that a medical home demonstration was associated with 29% fewer emergency visits, 6% fewer hospitalizations, and total savings of $10.30 per patient per month over a twenty-one-month period (p=0.08, a result that approaches statistical significance, meaning that the difference could still be due to chance). international comparisons in a study of 10 countries, the authors wrote that in most of the countries "health promotion is usually separate from acute care, so the notion of a... medical home as conceptualized in the united states... does not exist." nevertheless, the seven-country study of schoen et al. found that the prevalence of medical homes was highest in new zealand (61%) and lowest in germany (45%). controversy comparison with "gatekeeper" models some suggest that the medical home mimics the managed care "gatekeeper" models historically employed by hmos; however, there are important distinctions between care coordination in the medical home and the "gatekeeper" model. in the medical home, the patient has open access to see whatever physician they choose. no referral or permission is required. the personal physician of choice, who has comprehensive knowledge of the patient's medical conditions, facilitates and provides information to subspecialists involved in the care of the patient. the gatekeeper model placed more financial risk on the physicians resulting in rewards for less care. the medical home puts emphasis on medical management rewarding quality patient-centered care. organizations criticizing the model the medical home model has its critics, including the following major organizations: the american college of emergency physicians expresses cautions such as "a shifting of financial and other resources to support the pcmh model could have adverse effects on sectors of the health care system" and "there should be proven value in health care outcomes for patients and reduced costs to the health care system before there is widespread implementation of this model." the american optometric association is concerned that medical homes "may restrict access to eye and vision care" and requests "that optometry be recognized as a principal provider of eye and vision care services within the pcmh" the american psychological association states that congress should ensure that "careful consideration is paid to the role of psychologists and non-physician providers in the medical home model, which should be more appropriately named the 'health home model'." costs clinics compliant with principles of the patient-centered medical home may be associated with more operating costs. ongoing medical home projects one notable implementation of medical homes has been community care of north carolina (ccnc), which was started under the name "carolina access" in the early 1990s. ccnc consists of 14 community health networks that link approximately 750,000 medicaid patients to medical homes. it is funded by north carolina's medicaid office, which pays $3 per member per month to networks and $2.50 per member per month to physicians. ccnc is reported to have improved healthcare for patients with asthma and diabetes. non-peer-reviewed analyses cited in a peer-reviewed article suggested that ccnc saved north carolina $60 million in fiscal year 2003 and $161 million in fiscal year 2006. however, an independent analysis asserted that ccnc cost the state over $400 million in 2006 instead of producing savings. more recent analyses show that the program improved the quality of care for asthma and diabetes patients significantly, reducing emergency department and hospital use that produced savings of $150 million in 2007 alone. the rhode island chronic care sustainability initiative (csi-ri) is a community-wide collaborative effort convened in 2006 by the office of the health insurance commissioner to develop a sustainable model of primary care that will improve the care of chronic disease and lead to better overall health outcomes for rhode islanders. csi-ri is focused on improving the delivery of chronic illness care and supporting and sustaining primary care in the state of rhode island through the development and implementation of the patient-centered medical home. the csi-ri medical home demonstration officially launched in october 2008 with 5 primary care practices and was expanded in april 2010 to include an additional 8 sites. thirteen primary care sites, 66 providers, 39 family medicine residents, 68,000 patients (46,000 covered lives), and all rhode island payers are participating in the demonstration. further, its selection to participate in the centers for medicare and medicaid services' multi-payer advanced primary care practice demonstration, csi-ri is one few medical home demonstrations in the nation with virtually 100% payer participation. since the start of the demonstration, csi-ri sites have implemented a series of delivery system reforms in their practices, aimed at becoming patient-centered medical homes, and in turn receive a supplemental per-member-per-month payment from all of rhode island's insurers. each participating practice site also receives funding from participating payers for an on-site nurse care manager, who can work with all patients in the practice, regardless of insurance type or status. all 5 original pilot sites achieved ncqa level 1 ppc-pcmh recognition in 2009, and all 8 expansion sites achieved at least level 1 ppc-pcmh recognition in 2010. as of december 2010, all of the pilot sites and two of the expansion sites have been recognized by ncqa as level 3 patient-centered medical homes. carefirst has one of the largest projects, and in 2018 announced estimated savings of $1 billion over the prior eight years. projects evaluating medical home concepts the agency for healthcare research and quality offers grants to primary care practices in order for them to become patient-centered medical homes. the grants are designed to increase the evidence base for these types of transformations. as of december 31, 2009, there were at least 26 pilot projects involving medical homes with external payment reform being conducted in 18 states. these pilots included over 14,000 physicians caring for nearly 5 million patients. the projects are evaluating factors such as clinical quality, cost, patient experience/satisfaction, and provider experience/satisfaction. some of the projects underway are: division b, section 204 of the tax relief and health care act of 2006 outlined a medicare medical home demonstration project. this three-year project will involve care management reimbursement and incentive payments to physicians in 400 practices in 8 sites. it will evaluate the health and economic benefits of providing "targeted, accessible, continuous and coordinated, family-centered care to high-need populations." as of july 2009, however, the project had not yet started recruiting practices. in 2008, cigna and dartmouth-hitchcock announced they had launched a pilot program in new hampshire with 391 primary care providers. a unitedhealth group medical home pilot in arizona involving 7,000 patients and 7 medical groups began in 2009 and is scheduled to end in 2011. the state of maine provided $500,000 in 2009 for a pilot project in 26 practices. the new jersey academy of family physicians and horizon blue cross and blue shield of new jersey implemented a pilot project in march 2009. this project is ongoing and involves more than 60 primary care practice sites and 165 primary care physicians. specialties include family medicine/practice, internal medicine and multi-specialties in which 50% or more of the care provided is primary care. in 2006, transformed announced the launch of the national demonstration project aimed at transforming the way primary care is delivered in our country. the practice redesign initiative, funded by the aafp, ran from june 2006 to may 2008. it was the first and largest "proof-of-concept" project to determine empirically whether the transformed patient-centered medical home model of care could be implemented successfully and sustained in today's health care environment. more specifically, the project served as a learning lab to gain better insight into the kinds of hands-on technical support family physicians want and need to implement the pcmh model of care. learn more about national demonstration project between 2002 and 2006, group health cooperative made reforms to increase efficiency and access at 20 primary care clinics in western washington. these reforms had an adverse impact, increasing physician workload, fatigue, and turnover. negative trends in quality of care and utilization also appeared. as a result, the group health research institute developed a patient-centered medical home model in one of the clinics. by increasing staff, patient outreach and care management, the clinic reduced emergency department visits and improved patient perceptions of care quality. the role of pcmh and accountable care organizations (aco) in the coordination of patient care there are four core functions of primary care as conceptualized by barbara starfield and the institute of medicine. these four core functions consist of providing "accessible, comprehensive, longitudinal, and coordinated care in the context of families and community". in the pcmh model, the integration of diverse services that a patient may need is encouraged. this integration which also involves the patient in interpreting the streams of information and working together to find a plan that fits with the patient's values and preferences is under-recognized and under-appreciated. appropriate coordinated care depends on the patient or the population of patients and to a large extent, the complexity of their needs. the challenges involved with facilitating the delivery of care increases as the complexity of their needs increase. these complexities include chronic or acute health conditions, the social vulnerability of the patient, and the environment of the patient including the number of providers involved in their care. other factors that may play a role in the patient's coordination of care include their preferences and their ability to organize their own care. the increases in complexity may overwhelm informal coordinating functions requiring a care team that can explicitly provide coordinated care and assume responsibility for the coordination of a particular patient's care. according to the aco, care coordination achieves two critical objectives—high-quality and high-value care. acos can build on the coordinated