The Patient-Centered Medical Home (PCMH) Item Set enables users of the CAHPS Clinician & Group Survey to ask patients about their experiences with the domains of primary care that define a medical home. This item set is designed to be incorporated into the Clinician & Group 12-Month Survey.

A preassembled survey that combines the 12-Month Survey with the PCMH Item Set is available at: Get Clinician & Group Surveys and Instructions.

The PCMH Item Set is also available in the Supplemental Items for the Adult Surveys 1.1 ( PDF [ PDF file - 530.42 KB] ). The items are available in English and Spanish for both adults and children.

Read About the Patient-Centered Medical Home Item Set. ( PDF [ PDF file - 219.01 KB] )

Topics Covered by the PCMH Item Set

The PCMH Item Set both expands on topics in the 12-Month Survey and introduces new topics.

Expanded survey topics:

  • Access to care.
  • Coordination of care.

New survey topics:

  • Self-management support.
  • Shared decision making.
  • Comprehensiveness of care, including behavioral health and whole person orientation.
  • Information about getting care and appointments.

Quality Measures from the PCMH Item Set

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

  • Providers Pay Attention to Your Mental or Emotional Health (adult only)
  • Providers Support You in Taking Care of Your Own Health
  • Providers Discuss Medication Decisions (adult only)

Please note that these measure labels are provisional; the CAHPS team is testing the labels with consumers and may revise them based on the results of this testing.

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

Starting 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 with the domains of primary care that define a medical home. The process of developing and testing the expanded 12-Month Survey with 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.

Learn more about the development of the PCMH Item Set.

Also available:

For more information about this survey, go to: