| This survey is designed to help systems and provider practices move toward the “state-of-the-art” in delivering patient- |
| centered care in the context of a medical home. This assessment focuses on Empanelment, Registries and Care
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| Management. In the future, other components that complete the definition of “patient-centered medical home” will be |
| incorporated. The results can be used to help your team identify areas for improvement in Empanelment, Registries and |
| Care Management. Instructions are as follows: |
| |
| 1. Answer each question from the perspective of one physical site (e.g., CHC, HC, MACC). |
| |
| |
| 2. For each row, circle the point value that best describes the level of care that currently exists in the site. The rows |
| in this form present key aspects of patient-centered care related to Empanelment, Registries and Care Management. |
| Each aspect is divided into levels showing various stages in development. The stages are represented by points that |
| range from 1 to 12. The higher point values indicate that the actions described in that box are more fully |
| implemented. |
| |
| 1. Sum the points in each section (e.g., total part 1 score), and enter these scores in the space provided at the |
| end of each section. Then sum all of the section scores and complete the average score for the program as a whole |
| by dividing this by 15. |
| |
