Joint Commission Primary Care Medical Home Certification

Case Study: Heartland Health Centers, Chicago, IL


Heartland Health Centers is a federally qualified health center serving Chicago’s north side. They operate eight community health centers and six school-based health centers. Four of their SBHCs are well established in Chicago. Two additional SBHCs opened in 2015 in the village of Skokie, a northwestern suburb of Chicago. The organization decided to pursue Joint Commission (JC) accreditation and medical home certification because of their dedication to safety and high quality health services. They previously received JC Accreditation in 2013 and are up for renewal in 2016.

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The Approach Taken

Preparing for the JC onsite survey was a team effort. There are five managers for their 14 sites and they’d been working together to prepare. They utilized QI nurses to train the managers on the accreditation standards, including infectious disease control, CLIA waiver requirements, and safety. The managers then did tracers (or walk-throughs) of clinics they weren’t managing to assess compliance in the various areas. They recruited IT staff to pull data reports as needed. To meet PCMH certification requirements, Heartland invested in several program improvements. These included creating a patient portal, establishing care coordination teams, and implementing a system to assure students were scheduled, as often as possible, with the same primary care provider.


The greatest challenge for the Heartland Health Centers has been coordinating preparation activities between five managers and 14 sites. In addition, clinic staff members are busy—so it could be a struggle to keep the process moving forward.

“We had some confusion and misunderstanding on the part of parents with the promotion of the PCMH model,” reported Maria Paredes, RN, Manager of the SBHCs (personal communication, March 14, 2016). As the importance of a primary care provider has been stressed, some parents feared losing their community provider if they accessed SBHC services. This has required ongoing education about the complementary role of SBHC services and PCMH.

Impact/Lessons Learned

Ms. Paredes believes the process has improved patient care, particularly follow-up and care coordination: “It was a good choice for us given the Joint Commission’s long history of assuring safety and quality.”

Click here to view the Joint Commission's Primary Care Medical Home Certification process and its five operational characteristics.

TABLE 6: Joint Commission PCMH Standards

The Joint Commission’s Primary Care Medical Home Certification option is based on the Agency for Healthcare Research and Quality’s definition of a medical home, and includes these five operational characteristics.

StandardFocus (example)Measures (example)
Patient-centered careInformation about primary care home; designated PC clinician; patient involvement in own care decisions; patient language and communication needs; patient education, health literacy and self-management
  • provides information to the patient about PCMH
  • allows patient to select PCP
  • respects patient’s right to make decisions about the management of care
  • identifies the patient’s oral and written communication needs
  • identifies the patient’s health literacy needs

  • Comprehensive careExpanded scope of responsibility, team membership and responsibilities (must include MD or DO); care is comprehensive, coordinated, continuity is maintained; progress monitored
  • manages transitions in care and provides or facilities patient access to services needed
  • identifies the composition of the interdisciplinary team

  • Coordinated careCare coordination; internal and external referrals, developing and evaluating treatment plans, maintaining continuity of care
  • PCP is responsible for making certain that the interdisciplinary team provides comprehensive and coordinated care, and maintains the continuity of care
  • Superb access to carePatient has ability, 24 hours/7 days/week, to contact medical, request prescription renewal, obtain advice for urgent care needs; Flexible scheduling; online access to health information
  • provides patients ability 224/7 to obtain same or next day appointment, prescription renewal, and/or advice for urgent health needs
  • provides online access to their health information within four business days after the information is available to the PCP or interdisciplinary team

  • Systems for quality and safetyUse of EHR, electronic prescribing, use of clinical support tools, data collection for disease management outcomes; data collection on patient experience and satisfaction; patient involvement in performance improvement
  • uses e-prescribing for 50% of allowable prescriptions
  • uses clinical decision support tools to guide decision making
  • creates and submits registry reports to external providers and public health agencies
  • collects surveys on patients’ experience/li>
  • Note: These measures are validated by Survey Activity: Opening Conference/ Organization Orientation, Governing Board Session, Clinical/Leadership Sessions, Patient Tracer, Continuity of Care System Tracer, Medication Management System Tracer, Data Management Systems Tracers, and Competency Assessment.

    State Created Standards