The Patient-Centered Medical Home (PCMH) Item Set is a set of supplemental questions that can be added to the CAHPS Clinician & Group Survey to gather more information on patient experience with the domains of primary care that define a medical home.

To download the supplemental items with placement instructions, go to: Get the Clinician & Group Survey and Instructions.The items are available in English and Spanish for both adults and children.

Versions of the PCMH Item Set

Current version: 3.0. AHRQ released the Adult PCMH Item Set 3.0 in July 2015 to supplement the CG-CAHPS Survey 3.0. Updated Child items will be available in Fall 2015.

The Adult PCMH Item Set 3.0 includes 6 items, in contrast to the 18 items in version 2.0. The six items address four topics:

Topic: Self-management support

  • Anyone in provider’s office talked with patient about specific health goals
  • Anyone in provider’s office talked with patient about specific health goals
  • Anyone in provider’s office asked if there were things that made it hard for patient to take care of health

Topic: Coordination of care

  • Provider seemed informed and up-to-date about care from specialists

Topic: Whole person orientation

  • Anyone in provider’s office talked about worrying/stressful aspects of patient’s life

Topic: Information about getting care and appointments

  • Patient got information about what to do if care is needed on evenings, weekends, or holidays

Users of the PCMH Item Set 3.0 can add one new composite measure to the core measures produced by the CG-CAHPS Survey 3.0:

  • Talking with You About Taking Care of Your Own Health

The 12 items from the 2.0 version that are not included in the PCMH Item Set 3.0 remain available:

  • Two questions were incorporated into the core CG-CAHPS Survey 3.0.
  • Ten questions were moved into the general set of supplemental items.

2.0 Version. The 2.0 version of the PCMH Item Set has 18 items designed for the CG-CAHPS 12-Month Survey 2.0. These items are not meant to be integrated into the 3.0 version of the CG-CAHPS Survey.

Users of the PCMH Item Set 2.0 can report three patient experience measures in addition to the core measures from the CG-CAHPS 12-Month Survey 2.0. The composite measures unique to this item set are:

  • Talking with You About Taking Care of Your Own Health
  • Attention to Your Mental and Emotional Health (adult only)
  • Talking About Medication Decisions (adult only)

Read more about these two versions of the item set in About the Patient-Centered Medical Home Item Set ( PDF [ PDF file - 219.01 KB] ).

To see the items included in each of these composite measures, go to: Patient Experience Measures for the CAHPS Clinician & Group Surveys ( PDF [ PDF file - 446.73 KB] ).

Brief History

In late 2009, the CAHPS team began developing the PCMH Item Set to improve the usefulness of the CAHPS Clinician & Group 12-Month Survey as a tool for assessing patients’ experiences in medical homes. The process of developing and testing the PCMH items included multiple steps:

  • Literature review.
  • Input from a Technical Expert Panel and other stakeholders, in collaboration with the National Committee for Quality Assurance (NCQA).
  • Focus groups.
  • Cognitive testing in English and Spanish.
  • Development of a survey for field testing.
  • Field testing by NCQA of the draft version of the expanded 12-Month Survey with PCMH items.
  • Analysis of the field test results and refinement of the survey.

In 2015, the CAHPS team revised this set of items in response to feedback from stakeholders and users as well as findings from data analyses.

Learn more about the development of the PCMH Item Set.

Also available: