Colorado Residency Patient-Centered Medical Home Project

This database is no longer actively maintained and is here for archival purposes only

Organization Type: 
Educational Institution
Program Type: 
Standing Program
Education Level: 
Postgraduate (e.g., residency, fellowship)
Continuing Education
Educational Elements: 
Independent Study
Self Reflection Activities
Experiential not including services to patients
Experiential including clinical contact with patients
Other Element(s): 
Active participation on quality improvement teams and practice quality improvement efforts.
Program Description: 

The Colorado Residency Patient-Centered Medical Home (PCMH) Program is six-year grant from The Colorado Health Foundation that started in 2009.  This project is a collaboration among the University of Colorado Department of Family Medicine, HealthTeamWorks, the Colorado Association of Family Medicine Residencies, and the Colorado Institute of Family Medicine.  The project aims to assist Colorado’s Family and Internal Medicine Residency programs in PCMH practice improvement, incorporating a tandem approach that addresses both practice and curricular redesign.

The project is focused on the following: residency programs achieving National Committee for Quality Assurance (NCQA) medical home recognition, practice coaching, curricular redesign to integrate key PCMH components into resident education, development of a PCMH e-Learning curriculum as a tool for implementation of the medical home into resident education, practice baseline and follow-up assessments with results showing significant improvements in all aspects of implementation of the PCMH, and a Biannual learning collaborative.

Practice coaching, provided by the project, has facilitated the establishment of PCMH Steering Committees and Practice Improvement Teams, staff and resident engagement in quality improvement efforts, enhanced teamwork throughout the practice, and leadership alignment.

Project goals for the final three years of implementation include continuing with practice coaching to facilitate PCMH sustainability, the curriculum redesign efforts and development of the PCMH e-Learning modules, the leadership alignment, patient engagement and activation, implementation of patient self-management support systems in the practices, and emphasize on population management, development of patient registries, and use of data.

Program Results: 

Major project outcomes include: residency practice improvement in “medical homeness” as measured by assessment surveys; improvement in at least two chronic or preventive disease performance measures; increased clinician implementation of the Chronic Care Model; sustained practice improvement work; and residency program curricula changes incorporating the Chronic Care Model, quality improvement techniques and core PCMH concepts.

As of November 2013, seven programs had received NCQA Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH) Level 3 recognition, one received Level 2 recognition, and thre other programs will be submitting applications in the near future.

Two peer-reviewed publications have been written on this project including:

  • Fernald D, Deaner N, O’Neill C, Jortberg B, deGruy F, Dickinson WP. Overcoming early barriers to PCMH practice improvement in Family Medicine residencies. Family Medicine, 2011; p. 43(7):503-9.
  • Jortberg BT, Fernald DH, Dickinson LM, Coombs L, Deaner N, O’Neill C, deGruy FV, Green L, Dickinson WP. Curriculum redesign for teaching the PCMH in Colorado family medicine residency programs. Family Medicine. Fam Med 2014; 46(1): In press.
Targeted Professions
Family Medicine
Internal Medicine
Nurse Practitioners
Registered Nurses
Licensed Practical Nurses
Social Work: 
Medical social work
Medical Assistants
Patient Educators
Physician Assistants
Registered Dietitians
Self-Reported Competencies
PCPCC’s Education and Training Task Force identified 16 interprofessional training competencies critical for preparing health professionals for practicing in team-based, coordinated care models such as patient-centered medical homes. Listed below are the self-reported competencies that this program has achieved, which have been organized by the five core features of a medical home as defined by the Agency for Healthcare Research and Quality
Patient-Centered Care Competencies: 
Advocacy for patient-centered integrated care
Development of effective, caring relationships with patients
Patient-centered care planning, including collaborative decision-making and patient self-management
Comprehensive Care Competencies: 
Population-based approaches to health care delivery
Coordinated Care Competencies: 
Care coordination for comprehensive care of patient & family in the community
Interprofessionalism & interdisciplinary team collaboration
Team leadership
Quality Care & Safety Competencies: 
Evidence-based practice
Quality improvement methods, including assessment of patient-experience for use in practice-based improvement efforts
Accessible Care Competencies: 
Promotion of appropriate access to care (e.g., group appointments, open scheduling)
Last updated November 15, 2013

* Please note: Information contained in this database is self-reported by representatives from each program. It does not represent an exhaustive list of education and training programs and inclusion does not constitute an endorsement from the PCPCC.


Go to top