Original Publication
Open Access

Patient-Centered Medical Home (PCMH) Simulation: Planning for Coordinated Care Visits in the Primary Care Clinic

Published: May 14, 2014 | 10.15766/mep_2374-8265.9795

Included in this publication:

  • Instructor Guide PCMH.doc
  • Facilitator Guide.docx
  • Patient Case Summary and Instructions.docx
  • Discharge Summary.docx
  • Home Medication List.docx
  • Last Chart Note.docx
  • Team Member Reflection Form.docx
  • Facilitator Reflection Form.docx
  • Program Evaluation Form.docx
  • Interactive Module PCMH folder

To view all publication components, extract (i.e., unzip) them from the downloaded .zip file.

Editor's Note: This publication predates our implementation of the Educational Summary Report in 2016 and thus displays a different format than newer publications.


Introduction: This interprofessional education program is designed to prepare students in advanced-practice nursing and pharmacy for the interprofessional collaboration necessary to function in a patient-centered medical home. However, it can also be used with other students (medical or physician assistant) as the health care provider. Methods: Students use team communication skills and perform shared problem solving in a simulated team huddle to coordinate care of a patient with uncontrolled diabetes who was recently discharged from the hospital and is returning for follow-up and management in a primary care clinic. With guidance from a nurse care coordinator, the team works together to share information and design an action plan for this patient’s visit. This program was originally designed for students in doctor of nursing practice (DNP), doctor of pharmacy, and undergraduate nursing programs. Facilitator support is best with a 1:9 ratio (one facilitator for three groups of three learners each). Results: This exercise was implemented with first-year DNP students and third-year PharmD students in a graduate nursing course entitled: “Professional Interpersonal Styles of Communication with Families to Enhance Health Outcomes.” Evaluation of the simulation sessions included self-reflection on learning objectives, evaluation of team performance during huddles, evaluation of breakout sessions, and debriefing with students and faculty. The majority of students indicated the simulation achieved the learning objectives (M = 4.56 to 4.78; 1 = poor to 6 = excellent). Self-reflection occurred in four areas related to the case learning objectives: (1) Engage other health professionals (M = 4.67), (2) Express one’s knowledge and opinions to team members (M = 4.56), (3) Listen actively, and encourage ideas and opinions of other team members (M = 4.72), and (4) Integrate knowledge and experience of other professions (M = 4.78). The majority of students found the simulation a useful and interesting learning opportunity, helped them learn the value of team training, and was relevant to their future practice (mean scores 4.12 to 4.44). Upon debrief, faculty stated they observed good communication between professions, skill improvement with each huddle, and robust discussion of the team process. Discussion: This program introduces characteristics of the patient-centered medical home model of care. Faculty tasked with teaching students about these topics will find this exercise an interactive and engaging method for introducing concepts of the medical home and coordinated care visits.

Educational Objectives

By the end of this module, learners will be able to:

  1. Engage other health professionals—appropriate to a specific care situation—in shared patient-centered problem-solving. (IPEC Objective TT3)
  2. Express one’s knowledge and opinions to team members regarding patient care with confidence, clarity, respect, and working to ensure common understanding of information and treatment and care decisions. (IPEC Objective CC3)
  3. Listen actively, and encourage ideas and opinions of other team members. (IPEC Objective CC4)
  4. Integrate knowledge and experience of other professions—appropriate to the specific care situation—to inform care decisions, while respecting patient and community values, and priorities/preferences for care. (IPEC Objective TT4)
  5. Focus on collaboration and team communication skills more than the clinical decision making. However, some background on diabetes management may be necessary to help learners feel comfortable with their recommendations and plan.

Author Information

  • Jennifer Danielson, PharmD, MBA: University of Washington
  • Gail Johnson: University of Washington
  • Heather Davidson: University of Washington School of Medicine

None to report.

None to report.


Danielson J, Johnson G, Davidson H. Patient-centered medical home (PCMH) simulation: planning for coordinated care visits in the primary care clinic. MedEdPORTAL. 2014;10:9795. https://doi.org/10.15766/mep_2374-8265.9795