Table 2. Overview of Core Attributes, Standards and Measures of Oregon's Patient-Centered Primary Care Home Model

Core Attributes	Standards	Measures
Access to care: be there when we need you	In-person access Telephone and electronic access Administrative access	Appointment access After-hours appointments Telephone advice Electronic access Prescription refills
Accountability: take responsibility for making sure we receive the best possible health care	Performance improvement Cost and utilization	Performance improvement Clinical quality improvement Public reporting Ambulatory sensitive utilization
Comprehensive whole person care: provide or help us get the health care, information, and services we need	Scope of services	Preventive services Medical services Mental health and substance abuse services Health risk behavior assessment and intervention
Continuity: be our partner over time in caring for us	Provider continuity Information continuity Geographic continuity	Personal clinician assignment Personal clinician continuity Organization of clinical information Clinical information exchange Specialized care settings (hospital)
Coordination and integration: help us navigate the health care system to get the care we need in a safe and timely way	Data management Care coordination Care planning	Population data management Electronic health record Care coordination Test and result tracking Referral and specialty care coordination Comprehensive care planning 7. End of life planning
Person and family centered care: recognize that we are the most important part of the care team and that we are ultimately responsible for our overall health and wellness	Communication Education and self-management support Experience of care	Communication of roles and responsibilities Interpreter services Education and self-management support Patient experience survey