Skip to Content
800-533-8762
  • Careers
  • Newsroom
  • Health Care Professionals
  • About Us
  • Contact Us
UPMC
  • Find a Doctor
  • Services
    • Frequently Searched Services
    • Frequently Searched Services
      Allergy & Immunology Behavioral & Mental Health Cancer Ear, Nose & Throat Endocrinology Gastroenterology Heart & Vascular Imaging Neurosciences Orthopaedics
      Physical Rehabilitation Plastic & Reconstructive Surgery Primary Care Senior Services Sports Medicine Telemedicine Transplant Surgery Walk-In Care Weight Management Women’s Health
      See all Services
    • Services by Region
    • Find a UPMC health care facility close to you quickly by browsing by region.
      UPMC in Western Pa. Western Pa. and New York
      UPMC in Central Pa. Central Pa.
      UPMC in North Central Pa. North Central Pa.
      UPMC in Western Md. Maryland & West Virginia
    • See All Services
  • Locations
    • Locations by Type
    • Locations by Type
      UPMC hospitals
      Hospitals
      Physical Therapy
      Physical Therapy
      Urgent care
      Walk-In Care
      UPMC Outpatient Centers
      Outpatient Centers
      UPMC Imaging Services
      Imaging
      Community Health Centers
      Community Health Centers
      See All Locations
    • Locations by Region
    • Locations by Region
      UPMC in Southwest Pa. Southwest Pa.
      UPMC in North Central Pa. North Central Pa.
      UPMC in Northwest Pa and Ny. Northwest Pa. & Western N.Y.
      UPMC in West Central Pa. West Central Pa.
      UPMC in Central Pa. Central Pa.
      UPMC in Western Md. Maryland & West Virginia
    • See All Locations
  • Patients & Visitors
    • Patient & Visitor Resources
    • Patient & Visitor Resources
      Patients and Visitors Resources Pay a Bill Classes & Events Medical Records Health Library Patient Information
      Patient Portals Privacy Information Shared Decision Making Traveling Patients Visitor Information
      Man uses mobile phone
      Pay a Bill
      Nurse reviews medical chart
      Request Medical Records
  • Patient Portals
  • Find Covid-19 updates
  • Schedule an appointment
  • Request medical records
  • Pay a bill
  • Learn about financial assistance
  • Find classes & events
  • Send a patient an eCard
  • Make a donation
  • Volunteer
  • Read HealthBeat blog
  • Explore UPMC Careers
Skip to Content
UPMC
  • Patient Portals
  • For Patients & Visitors
    • Find a Doctor
    • Locations
    • Patient & Visitor Resources
    • Pay a Bill
    • Services
    • More
      • Medical Records
      • Financial Assistance
      • Classes & Events
      • HealthBeat Blog
      • Health Library
  • About UPMC
    • Why UPMC
    • Facts & Stats
    • Supply Chain Management
    • Community Commitment
    • More
      • Financials
      • Support UPMC
      • UPMC Apps
      • UPMC Enterprises
      • UPMC International
  • For Health Care Professionals
    • Physician Information
    • Resources
    • Education & Training
    • Departments
    • Credentialing
  • Careers
  • Contact Us
  • Newsroom
  • UPMC >
  • Media Relations >
  • News Releases >
  • medical home chronic disease management
Media Relations
News Releases
Central Pa. News
North Central Pa. News
Contact Us
Experts
Community-Focused News
Media Kits
Media RSS
Media Relations
News Releases
Central Pa. News
North Central Pa. News
Contact Us
Experts
Community-Focused News
Media Kits
Media RSS

Chat Keywords List

  • cancel or exit: Stops your conversation
  • start over: Restarts your current scenario
  • help: Shows what this bot can do
  • terms: Shows terms of use and privacy statement
  • feedback: Give us feedback
Continue
Chat with UPMC
RESTART
MENU
CLOSE

Patient-Centered Medical Home Model Improves Chronic Disease Management

For Journalists

Courtney Caprara
Manager
412-647-6190
capraracl@upmc.edu

Allison Hydzik
Director, Science and Research
412-647-9975
hydzikam@upmc.edu

Want to Make an Appointment or Need Patient Information?
Contact UPMC at

1-800-533-8762.

Go to Find a Doctor to search for a UPMC doctor.

10/20/2017

Main Content

PITTSBURGH, Nov. 20, 2017 – Data from more than 800 Veterans Health Administration (VHA) primary care clinics revealed that national implementation of a patient-centered medical home model was effective at improving several chronic disease outcomes over time. Findings were published online today in Health Services Research.

The VHA launched its Patient Aligned Care Teams (PACT) initiative in 2010, the largest program in the country to implement patient-centered medical home care. The VHA assigned each of the network’s 5 million primary care patients to a “teamlet” designed to provide multidisciplinary health care support focused on patients’ individual needs. Similar models are being implemented and tested in health systems across the country.

Over the course of four years, a team of researchers led by Ann-Marie Rosland, M.D., associate professor of internal medicine, University of Pittsburgh School of Medicine, analyzed medical records from all 808 participating clinics to measure 15 clinical outcomes and clinical processes to determine how the PACT model influenced care for patients with coronary artery disease, diabetes and hypertension. These three common and costly chronic diseases can lead to significant complications and disability if they are not controlled.

All VHA clinics were given access to the same resources, tools and training to implement the PACT model, which addresses eight areas of care: access, continuity, coordination, team-based care, comprehensiveness of care, self-management support, patient-centered communication and shared decision-making. No control group was designated, but some clinics had naturally implemented more elements of the program than others by 2012, and analyses adjusted and accounted for various differences among the high and low implementation clinics.

The 77 clinics that most fully executed the PACT model by 2012 had significantly larger improvements in five of seven chronic disease outcome measures and two of eight clinical process measures compared to the 69 clinics with the fewest PACT elements implemented. Researchers found that clinics with the most advanced PACT implementation saw 1 to 5 percent more of their patients meeting established levels for diabetes, blood pressure and cholesterol control.

“Most studies of comprehensive medical home models have not been able to assess the impact they have on the control of chronic conditions, such as whether patients are bringing their sugar levels down to recommended goals. They have been able to look only at whether doctors and nurses are following recommended processes, such as whether sugar levels are being checked in the clinic,” said Rosland, who also has an appointment at the VA Pittsburgh Center for Health Equity Research and Promotion. “All VHA primary care patients were provided with PACT’s team-based care, and we were able to identify that this model of care, when well-implemented, translated into better outcomes for patients with chronic conditions.

“While not every clinical measure improved as significantly as others with increased implementation of the PACT model, this study demonstrates that health systems that invest in changes in care delivery through a medical home model for all primary care patients could see downstream improvements in the management of those patients with chronic diseases,” added Rosland.

This research was conducted while Rosland was an associate professor at the University of Michigan, where she also held a position at the VA Ann Arbor Center for Clinical Management Research. The VA Office of Primary Care Services and Office of Primary Care Operations provided the research funding.
UPMC
200 Lothrop Street Pittsburgh, PA 15213

412-647-8762 800-533-8762

Patients And Visitors
  • Find a Doctor
  • Locations
  • Pay a Bill
  • Patient & Visitor Resources
  • Disabilities Resource Center
  • Services
  • Medical Records
  • No Surprises Act
  • Price Transparency
  • Financial Assistance
  • Classes & Events
  • Health Library
Health Care Professionals
  • Physician Information
  • Resources
  • Education & Training
  • Departments
  • Credentialing
Newsroom
  • Newsroom Home
  • Inside Life Changing Medicine Blog
  • News Releases
About
  • Why UPMC
  • Facts & Stats
  • Supply Chain Management
  • Community Commitment
  • Financials
  • Supporting UPMC
  • HealthBeat Blog
  • UPMC Apps
  • UPMC Enterprises
  • UPMC Health Plan
  • UPMC International
  • Nondiscrimination Policy
Life changing is...
Follow UPMC
  • Contact Us
  • Website/Email Terms of Use
  • Medical Advice Disclaimer
  • Privacy Information
  • Active Privacy Alerts
  • Sitemap
© 2025 UPMC I Affiliated with the University of Pittsburgh Schools of the Health Sciences Supplemental content provided by Healthwise, Incorporated. To learn more, visit healthwise.org
Find Care
Providers
Video Visit
Portal Login