Patient-Centered Medical Home Demonstration Project


In 2010, five California health care provider organizations were awarded $6.3 million over three years to establish Patient-Centered Medical Home (PCMH) Demonstration Projects. The initiative is evaluating the effectiveness of PCMH models of care for people living with HIV, which holds the promise of reducing costs, improving care coordination, and increasing quality and outcomes of care. 

‘PCMH’ refers to an integrated system or group of providers of care, treatment, prevention and support services that provides coordinated, high quality, client-centered services.  A PCMH often utilizes electronic portals and record systems for improved coordination between providers and communication with patients.  Examples of PCMH services which can be linked and coordinated include out-patient care, home health care, nutrition, mental health, and pharmacy.  The PCMH model is now a key new component of the Federal Affordable Care Act.

This research will provide tremendous value to HIV care providers, policy makers, and health care system planners in California and nationwide.  Over 20% of Californians living with HIV infection and in care are served by clinics funded through this initiative.  This demonstration project has significant implications in the design and delivery of care to persons with other chronic diseases such as diabetes and hypertension.

Demonstration Projects


Grantees are testing a number of strategies through their PCMH models. Examples of strategies at one or more sites:

The grantees are testing a number of strategies through their PCMH models. Examples include:

  • Population-based panel management
  • Multidisciplinary treatment groups
  • Shared medical appointments
  • Individual provider quality report cards
  • Clinic-based medical care coordination teams
  • New patient flows
  • Web-based patient portals, including Spanish-language
  • Integration of geriatrics and HIV care for populations 50 and over
  • Shared EHRs for outpatient care, dental care, home health case management, and emergency care.
  • Automated eligibility for Ryan White funded services
  • Capacity building to prepare for PCMH recognition from NCQA
  • Staff coaching
  • IT staff participation in select clinical care team meetings

The grantees are evaluating the impact of their models and strategies through a collaborative research effort coordinated by the Center for AIDS Prevention Studies at the University of California, San Francisco.


Retention: Building a Patient-Centered Medical Home in HIV Primary Care through PUFF (Patients Unable to Follow-up Found)
Sitapati, Amy M., Jan Limneos, Militza Bonet-Vázquez, Moira Mar-Tang, Huifang Qin, and W. Christopher Mathews. "Retention: Building a Patient-Centered Medical Home in HIV Primary Care Through PUFF (Patients Unable to Follow-up Found)." Journal of Health Care for the Poor and Underserved 23, no. 3 (2012): 81–95.

Example of a patient portal: ANCHOR MyUCSDChart
Example of a project website: HIV ACCESS
PCMH education videos:  Voices from the Field
Example of a provider education newsletter
Research Presented at the HRSA Ryan White All Grantee Meeting: November 27-29, 2012