Patient-Centered Medical Home Model Curriculum

Prepare learners for interprofessional collaboration necessary to function in a patient-centered medical home (PCMH).


The “Patient-Centered Medical Home (PCMH) Simulation: Planning for Coordinated Care Visits in the Primary Care Clinic” curriculum, available from MedEdPORTAL, introduces concepts of the medical home and coordinated care visits. This program was originally designed for trainees in doctor of nursing practice, doctor of pharmacy (third professional year), and undergraduate nursing programs. Physician or physician assistant trainees could take the role of primary care provider. A variety of nursing or social work students could serve as care coordinators. Medical assistants, if available, could be added to more closely mimic the mix of professionals often seen in primary care clinics. Facilitator support is best with a 1:9 ratio (one facilitator for three groups of three learners each).


To engage learners in shared-problem solving for chronic disease management and transitional care.

To introduce learners to methods for collaborative practice (team huddles and patient-centered coordinated care visits) in the PCMH.

To familiarize learners with the role of a care coordinator in primary care.


This IPE curriculum focuses on team communication skills and 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 care coordinator, the team works together to share information and design an action plan for this patient’s visit. This simulation was part of three interprofessional learning activities including a brief TeamsSTEPPS® training, breakout simulation sessions in which teams of students participated in team huddles, and a large group debriefing session. 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 TeamSTEPPS® team training exercise is not provided in the MedEdPORTAL curriculum. Click here to access the TeamSTEPPS® team training exercise available from our website.

All materials and instructions are available from MedEdPORTAL, an open exchange of peer-reviewed health education teaching and assessment resources to promote educational scholarship and promote collaboration, provided by the Association of American Medical Colleges (AAMC).


Danielson, J., Johnson, G., & Davidson, H. (2014). Patient-centered medical home (PCMH) simulation: planning for coordinated care visits in the primary care clinic. MedEdPORTAL Publications:

Learning Objectives

By the end of this session, the learner will:

  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 involved in patient care with confidence, clarity, respect, 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)

Facilitators and students should focus on collaboration and team communication skills more than the clinical decision making. Some background on diabetes management may be necessary to help learners feel comfortable with their recommendations and plan.


Interprofessional Education Collaborative Expert Panel. (2011). Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative.


The content of this IPE Curriculum was developed by an IPE curriculum development and team at the University of Washington  with financial support from the The Josiah Macy, Jr. Foundation;  and the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under grant number U1KHP09543 and title “Faculty Development: Integrated Technology into Nursing Education & Practice Initiative.”

Curriculum Development Team Members:
Jennifer Danielson, PharmD, MBA
Heather Davidson, MD
Gail Johnson, DNP, ARNP, FNP-BC
Chia-Ju Chiu, PhD, PT
Debra Liner, PMP