Patient-Centered Care

The Patient Comes First

In a medical home, the practice is organized around the patient– communication is based on trust, respect, and shared decision-making. Patients want access to personalized, coordinated, and comprehensive primary care when they need it, when it's convenient for them. They also want convenient access to practice information.

Patient-Centered Care Tool

Group Visits

Research indicates that patients value group visits, and that participating in these visits can motivate behavior change and improve health outcomes. Group visits save time, allow for more focused education, and give patients a chance to share experiences and support each other.

When patients arrive for a group visit, ask them to complete a condition-specific health review form. For example, use the Diabetes Review of Systems(1 page PDF) for group visits with patients who have diabetes. During the visit, give each patient his or her laboratory test results; this will facilitate group discussion and help patients take an active role in managing their condition. The Know Your Diabetes ABCs(1 page PDF) form is one example of an easy way to summarize this information.

Supported by an educational grant to the American Academy of Family Physicians from GlaxoSmithKline.

Provide Convenient Care

Convenience is key for most patients; find out how you can offer same-day appointments.

Offer Same-day Appointments

Assemble a Project Team
Get staff involved. Staff commitment and buy-in are essential to the success of open-access scheduling implementation.

Assess Demand for Same-day Appointments
Availability and demand for appointments must be in balance for open-access scheduling to succeed.

Allocate Resources
Additional short-term staff and financial resources may be required.

Assess Clinical Staff Resources
Optimize patient care by analyzing efficiency of processes and use of clinical staff resources.

Educate & Train Staff
Provide leadership and education on the principles and benefits of open-access scheduling.

Free-up Appointment Slots
Get your project started.

Evaluate the Scheduling Service
Monitor data to find out how open-access scheduling is working for you.

Develop Your Practice's Online Presence

Create your practice website first, then add interactive services through a secure patient portal.

Create a Practice Website

This essential first step to having an online presence gives potential and existing patients convenient access to information about your practice.

Assemble a Project Team
The team will help you get the website up and running, then play a role in marketing, maintaining, and evaluating the site.

Select a Company
If your practice is like most others, you'll work with an outside company to develop your website because you don't have the time or the expertise to go it alone.

Develop Content for Your Website
Decide what information to include on the website and get it written.

Market Your Website
Develop a plan for promoting the website to potential and existing patients.

Improve & Evaluate: Practice Website
Visitors will appreciate fresh, accurate content and a website that functions well.

Schedule Appointments Online

This convenient, secure service is available to patients 24/7, not just when your office is open and it will save your staff time, too.

Assemble a Project Team
Pick team members, schedule team meetings, and develop a timeline for the project team.

Do Your Research
Collect and analyze information to decide if online appointment scheduling is right for your practice.

Establsih Workflow
Figure out how to integrate online appointment scheduling into regular office workflow.

Select a Product
Evaluate vendors with systems that interest you, then pick a product.

Market to Online Appointments to Patients
Make patients aware of this convenient new service and how to access it.

Improve & Evaluate: Online Appointments
After the system's up and running, get feedback on how it's working.

Email with Patients (Health Information Technology)

Freeze tag is fun; phone tag is frustrating. Offering your patients the opportunity to communicate with your practice via email can improve their satisfaction and can reduce the amount of time your staff spends returning missed calls.

Assess Readiness
Data gathered from a patient survey and phone call tracking exercise can tell you whether the time is right to start using email to communicate with patients.

Create an Email Policy
Having a thoughtful and documented policy in place supports both the provider and the patient.

Establish Workflow: Email
As with any standard operating procedure, orderly workflows support you, your office staff, and patients.

Select a Product
We can't tell you which system to buy, but we can help you decide what functionality is important and help you gather data from your peers.

Market Your Email Service
Promoting your service will bring quicker results than word-of-mouth alone, so learn some simple ways to spread the word.

Evaluate the Email Service
You, your staff, and your patients all have opinions about how things can work better. Ask how, and put suggestions into practice.

Assess Patient Satisfaction

How good is customer service in your practice? Your patients know.

Use Patient Satisfaction Data to Improve

Assess Readiness
Are you ready to improve patient service? If you are, get your staff ready, too.

Assemble a Project Team
Select the right people for the team and develop a work plan.

Hold a Patient Focus Group
Invite patients to share their opinions about customer service in your practice.

Conduct a Patient Satisfaction Survey
You'll learn where your customer service is glowing and where it could improve.

Implement Practice Improvement Projects
Your patients pointed out where to improve customer service. Now, tackle those areas one by one and make them better.

Get Patients Involved in Their Care

It's their health, so activate their engagement for better outcomes.

Support Patient Self-management

Patients with knowledge, skills, confidence, and motivation make better choices, which leads to improved outcomes.

Financial support provided by the American Academy of Family Physicians Foundation.

FAQ on Patient Self-management
Get answers to the frequently asked questions regarding patient self-management, including motivational interviewing, health coaching, and team models for integrating self-management support.

Assess Readiness
Learn more about patient self-management support, select a project team, and talk to others in the practice.

Create a Plan
Hold the first team meeting and develop a work plan.

Educate & Experiment
After your team learns about self-management support techniques and tools, try them with a small number of patients, evaluate and modify, and try again. You'll determine what works best in your practice.

Establish Workflow
Once you know what works best, modify your workflow and shift roles and responsibilities to make room for self-management support.

Expand & Sustain
Eventually, patient self-management support will become "usual care" in your practice.

Join a free collaborative online network committed to practice transformation. Learn more about Delta-Exchange.

This Patient-Centered Medical Home section of the AAFP web site was supported in part by a grant from Merck & Co.

On-Demand Webinar: Preparing Your Practice for Group Visits

  • Understand the components to implementing a group visit.
  • Understand how practices can successfully get paid for group visits.
  • Access new AAFP tools that can help to plan and implement group visits in practice.
  • Be prepared to share with your staff why group visits are important and prepare them for adopting this new process.

Register to view the archived webinar.(

Read the Patient Self-management FAQ.

Get the answers to your questions about patient self-manageement with our FAQ.

Read the PSM FAQ »

PCMH Planner

Enhance your patient care with the PCMH Planner. Step-by-step guides to improving patient self-management include motivational interviewing, home monitoring, and health coaching.

Learn More »