Key Functions of a Medical Home

Care Management

The Medical Home Checklist

Ready to position your practice to better respond to the changing health care landscape? Learn how to get started.

The American Academy of Family Physicians defines a medical home as one that is based on the Joint Principles of the Patient-Centered Medical Home (PCMH)(3 page PDF) and the five key functions of the Comprehensive Primary Care Plus (CPC+) initiative.

Learn more about care management, one of the five key functions of medical homes. 

What is Care Management?

Care management refers to activities performed by health care professionals with a goal of facilitating coordinated patient care across the health care system.

Although care management programs increase patient satisfaction and improve outcomes, these services are typically not reimbursed under traditional fee-for-service payment models. Examples of care management services include:  

  • Patient education
  • Medication management and adherence support
  • Risk stratification
  • Population management
  • Coordination of care transitions
  • Care planning

For examples of care management implementation in practice, see the Robert Graham Center's Bright Spots in Care Management report(

The Cost of Care Management

Significant activity across the country is currently aimed at optimizing care management in primary care practices, working to deliver high-quality care at lower costs, especially related to the adoption of patient-centered medical home (PCMH) functions.

This activity includes (but is not limited to):

The resources necessary to deliver care management vary widely depending upon the program and characteristics of the primary care practice implementing the program. A Robert Graham Center presentation( found services covered under public and private care management programs ranged from simple teaching plans with educational modules to using registered nurses and social workers as care managers.


Transform your practice with AAFP TIPS™, providing ready-to-use resources to help you make small changes that yield big results.

The Medical Home Checklist

Ready to position your practice to better respond to the changing health care landscape? Learn how to get started.

Implement Risk-Stratified Care Management

The AAFP has created a comprehensive rubric to help you identify your patients' risk category. This full-color PDF can be printed legal- or poster-size for guidance through the RCSM process.

Free for Members

Log in to your AAFP member account and download the PDF for free (a $50.00 value)!

Non-members: Purchase the downloadable, full-color PDF.
Non-member price: $50.00

Care Management Calculator

The cost of care management for any practice has a significant influence on a practice's ability to actually deliver care management.

The ability to calculate the actual incremental cost of care management is difficult. Many factors need to be integrated to arrive at a reasonable and accurate estimate of care management costs and to estimate the ability of a practice to cover those costs, including:

  • The attributes of the patient panel
  • The staff involved in care management
  • Revenue streams the practice receives for care management

To ease this administrative burden, the AAFP worked with Discern Health to develop a calculator to estimate care management costs. This tool was designed to assess various factors that might influence care management costs and to provide an estimate of care management costs and savings based on:

  • Staffing hours
  • Overhead
  • The chronic disease burden of the patient panel
  • The state where the practice is located
  • Revenue from care management billing or program funds

The calculator is Excel-based and organized in a stepwise process.

Download the Care Management Calculator»(486 KB XLSM)

Valuation of Care Management Performed by Primary Care Physicians: An Issue Brief prepared by Discern Health

Health insurers have begun increasing payments to primary care physicians because of the important role they play in the shift from volume to value.

As managers of patients’ overall care, primary care physicians are key to keeping patients healthy and out of the hospital. This brief explores the value primary care physicians create through care management and how this value might be included in payments.

Read the Valuation of Care Management Performed by Primary Care Physicians»(7 page PDF)

Risk-Stratified Care Management

Risk-stratified care management (RSCM) is the process of assigning a health risk status to a patient, and using the patient’s risk status to direct and improve care. The goal of RSCM is to help patients achieve the best health and quality of life possible by preventing chronic disease, stabilizing current chronic conditions, and preventing acceleration to higher-risk categories and higher associated costs.

Identifying a patient's health risk category is the first step toward planning, developing, and implementing a personalized care plan by the care team, in collaboration with the patient. For some, the plan may address a need for more robust care coordination with other providers, intensive care management, or collaboration with community resources.

In a practice panel of 1,000 patients, there will likely be close to 200 patients (20%) who could benefit from an increased level of support. This 20% of the population accounts for 80% of the total health care spending in the United States, with the very highest medical costs concentrated in the top 1% (via the Commonwealth Fund Issue Brief, May 2011(

Efforts to implement RSCM have the added benefit of preparing a practice to respond to payment reform. Future health care payment models will likely require practices to have a method for systematically categorizing and monitoring their patient populations, so that reimbursement adjustments can be rendered for the additional care and resources the health care team provides to high-risk patients.


Transform your practice with AAFP TIPS™, providing ready-to-use resources to help you make small changes that yield big results.