Transforming Outcomes for Patients through Medical home Evaluation & redesign (TOPMED)

funded by the Gordon and Betty Moore Foundation

Executive Summary


Impact and Opportunity


Oregon Health & Science University has begun a $1.6 million, three-year partnership with the Gordon and Betty Moore Foundation to deliver safer, more effectively coordinated health care in primary care, especially to at-risk patients affected by multiple chronic conditions. This partnership will enable OHSU to leverage its unique expertise in the design of health care management models to improve and measure the safety, effectiveness and experience of patient care in Medical Home models such as the Patient-Centered Primary Care Home (PCPCH). OHSU already has an innovative model in place – Care Management Plus – which has been disseminated in more than 160 primary care clinics, large and small. In this project, we will expand its scope, tailor it to the emerging environment of the PCPCH concept, establish ways to measure its effectiveness in four diverse care settings, and work to export our findings across the United States. This impact is achievable based on our significant prior success with Care Management Plus, the expertise and existing collaborations of our faculty, and Oregon’s leadership in health reform. This grant will create a national impact as other states adopt best practices, and as potentially millions of vulnerable patients enjoy better outcomes through more effectively coordinated care.


The Problem


The Medical Home model is a cornerstone of U.S. health reform policy because of its potential to reduce the cost and increase the safety and quality of care for millions of patients with multiple chronic conditions, especially as the population ages. The challenge facing most health providers, however, is how to interpret and implement the broad Medical Home related goals of federal reform in an efficient and sustainable way. This study will address payment models, distribution of benefits and risks across the patient population, quality measurement and feedback systems, and engagement of communities and care-site populations, among other key issues. This research meets a critical need.


Project Description

This grant will address the important issue of how to improve the quality of clinical care for adults with chronic illness, while reducing hospitalization, and providing a high level of patient satisfaction.  The research team will undertake a randomized controlled trial at eight clinics in four diverse health care settings: 1) small clinics in rural areas, 2) moderate-sized clinics in rural areas, 3) clinics in moderate-sized health systems, and 4) an academic medical center. The study will determine whether the Care Management Plus (CMP) model, enhanced with high value elements of the Patient Centered Medical Home will lead to improved patient outcomes (quality of care, patient experience, utilization) and lowered costs of care.  Health information technology (HIT) support is a key component of the enhanced intervention, and will be used to track patient quality indicators, and implementation status of the recommended components of the primary care medical home.   Health care payers will be engaged early in the project to develop an action plan for reimbursement for the care model in order to promote sustainability.

 For more information, contact or visit