Table 2. Overview of Core Attributes, Standards and Measures of Oregon's Patient-Centered Primary Care Home Model
Core AttributesStandardsMeasures
Access to care: be there when we need you
  • In-person access

  • Telephone and electronic access

  • Administrative access

  1. Appointment access

  2. After-hours appointments

  3. Telephone advice

  4. Electronic access

  5. Prescription refills

Accountability: take responsibility for making sure we receive the best possible health care
  • Performance improvement

  • Cost and utilization

  1. Performance improvement

  2. Clinical quality improvement

  3. Public reporting

  4. Ambulatory sensitive utilization

Comprehensive whole person care: provide or help us get the health care, information, and services we needScope of services
  1. Preventive services

  2. Medical services

  3. Mental health and substance abuse services

  4. Health risk behavior assessment and intervention

Continuity: be our partner over time in caring for us
  • Provider continuity

  • Information continuity

  • Geographic continuity

  1. Personal clinician assignment

  2. Personal clinician continuity

  3. Organization of clinical information

  4. Clinical information exchange

  5. 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

  1. Population data management

  2. Electronic health record

  3. Care coordination

  4. Test and result tracking

  5. Referral and specialty care coordination

  6. 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

  1. Communication of roles and responsibilities

  2. Interpreter services

  3. Education and self-management support

  4. Patient experience survey