Journal of General Internal Medicine

, Volume 28, Issue 9, pp 1195–1201 | Cite as

The Patient Centered Medical Home: Mental Models and Practice Culture Driving the Transformation Process

  • Peter F. Cronholm
  • Judy A. Shea
  • Rachel M. Werner
  • Michelle Miller-Day
  • Jim Tufano
  • Benjamin F. Crabtree
  • Robert Gabbay
Original Research



The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. The PCMH model is a departure from more traditional models of healthcare delivery and requires significant transformation to be realized.


To describe factors shaping mental models and practice culture driving the PCMH transformation process in a large multi-payer PCMH demonstration project.


Individual interviews were conducted at 17 primary care practices in South Eastern Pennsylvania.


A total of 118 individual interviews were conducted with clinicians (N = 47), patient educators (N = 4), office administrators (N = 12), medical assistants (N = 26), front office staff (N = 7), nurses (N = 4), care managers (N = 11), social workers (N = 4), and other stakeholders (N = 3). A multi-disciplinary research team used a grounded theory approach to develop the key constructs describing factors shaping successful practice transformation.


Three central themes emerged from the data related to changes in practice culture and mental models necessary for PCMH practice transformation: 1) shifting practice perspectives towards proactive, population-oriented care based in practice–patient partnerships; 2) creating a culture of self-examination; and 3) challenges to developing new roles within the practice through distribution of responsibilities and team-based care. The most tension in shifting the required mental models was displayed between clinician and medical assistant participants, revealing significant barriers towards moving away from clinician-centric care.


Key factors driving the PCMH transformation process require shifting mental models at the individual level and culture change at the practice level. Transformation is based upon structural and process changes that support orientation of practice mental models towards perceptions of population health, self-assessment, and the development of shared decision-making. Staff buy-in to the new roles and responsibilities driving PCMH transformation was described as central to making sustainable change at the practice level; however, key barriers related to clinician autonomy appeared to interfere with the formation of team-based care.


patient-centered care primary health care delivery of health care workplace program evaluation 



The authors wish to thank Katherine Kellom and Shimrit Keddem from the University of Pennsylvania’s Department of Family Medicine and Community Health’s Mixed Methods Research Lab (, Patricia L. Bricker from the Penn State Hershey Diabetes Institute, and Dana Naughton Pennsylvania State University, Department of Communication Arts and Sciences for their contributions to program coordination, data collection and data management.


This project was supported by a grant from the Agency for Healthcare Research and Quality (5R18HS019150) and funds from Aetna Foundation.

Prior Presentations

These data were submitted for as an abstract for presentation at the 2012 North American Primary Care Research Group (NAPCRG). The submission is pending review.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


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Copyright information

© Society of General Internal Medicine 2013

Authors and Affiliations

  • Peter F. Cronholm
    • 1
    • 2
    • 3
  • Judy A. Shea
    • 4
  • Rachel M. Werner
    • 4
    • 5
  • Michelle Miller-Day
    • 6
  • Jim Tufano
    • 7
  • Benjamin F. Crabtree
    • 8
  • Robert Gabbay
    • 9
  1. 1.Department of Family Medicine and Community HealthThe University of PennsylvaniaPhiladelphiaUSA
  2. 2.Center for Public Health InitiativesUniversity of PennsylvaniaPhiladelphiaUSA
  3. 3.Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Division of General Internal MedicineUniversity of PennsylvaniaPhiladelphiaUSA
  5. 5.Philadelphia VA Medical CenterPhiladelphiaUSA
  6. 6.Department of Communication StudiesChapman UniversityOrangeUSA
  7. 7.Department of Biomedical Informatics & Medical EducationUniversity of Washington School of MedicineSeattleUSA
  8. 8.Department of Family Medicine and Community HealthUMDNJ-Robert Wood Johnson Medical SchoolNew BrunswickUSA
  9. 9.Penn State Hershey Diabetes Institute, Penn State College of Medicine, Diabetes ProgramPenn State Milton S. Hershey Medical CenterHersheyUSA

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