Atlantic General Receives $1 Million Grant for Patient Centered Medical Home


Atlantic General Hospital is among the grant recipients of The Centers for Medicaid and Medicare Services’ Healthcare Innovation Award. A total of $1,097,512 over three years will be provided to the healthcare organization, which they will use to extend their patient-centered medical home (PCMH) program to patients in their primary care practices in Berlin, Ocean Pines, Snow Hill, Pocomoke, and Ocean City, Md. and Selbyville and Ocean View, Del. The hospital is currently involved in two pilot projects to provide PCMH services to patients in their physician practices, but the new grant dollars will further expand those services for a larger number of patients.

The funds will be used to hire a patient care manager, care team coordinator and a patient advocate, among others, to create and maintain the medical home structure, which is a team-based approach to caring for the whole person. Specifically, the program will target Medicare patients diagnosed with congestive heart failure, chronic obstructive pulmonary disease (COPD) and diabetes. The goal is to increase access to healthcare for individuals with these chronic diseases and better coordinate their overall care delivery across the healthcare spectrum from inpatient care to rehabilitation services through to outpatient preventive care and specialty medicine. The end result being better managed chronic conditions to keep patients healthier and out of the hospital.

Atlantic General is excited about the funding announcement and eager to move forward with program development and recruitment efforts so they can achieve their target of reduced hospital admissions and ER visits.

The PCMH Program will be complemented by the PERKS Portal, a secure web site where patients of Atlantic General Hospital and Health System (or their caregivers) can track their medical histories, review test results, communicate with their doctors’ office, and receive reminders about important preventive screenings as well as the encouragement they need to adopt healthy life practices. The PERKS Portal is due to launch this fall.

“This is a substantial and very important award for the future of health and health care in our community,” said Michael Franklin, CEO of Atlantic General Hospital and Health System. “This award will accelerate our evolution to a healthcare system that is focused on keeping people healthy in our community, and reducing the incidence of health-related crises that are associated with chronic illness. This is the future of healthcare for all communities.”

What is a Patient-Centered Medical Home?
The patient-centered medical home (PCMH) is a concept, not a specific place. It’s anywhere a team of healthcare professionals, guided by the primary care provider, provides comprehensive, coordinated care for the patient over their lifetime. This model actively embraces input and participation from the patient and the patient’s family. The PCMH team is structured to provide for all of a patient’s healthcare needs, or work with other healthcare professionals to meet those needs.

The model has been developed to address inefficiencies in the current fragmented healthcare system in the U.S. In its current state, U.S. healthcare allows for the possibility of multiple disconnects among the various healthcare providers who might care for a single patient, which can result in duplicative testing and less than optimal management of chronic conditions. The PCMH focuses on a preventive, holistic approach and brings the disparate efforts together in a coordinated manner that makes better sense for each patient.

It’s also designed to decrease the healthcare cost burden. By coordinating care among a patient’s specialists and healthcare centers, diagnostic results can be shared rather than repeated. Ongoing health conditions can be better managed, thus avoiding more intensive, and therefore expensive, care.

About Atlantic General Hospital
Atlantic General Hospital has been providing quality health care to the residents of Worcester, Wicomico, Somerset (Md.) and Sussex (Del.) Counties since May 1993. Built by the commitment and generosity of a dedicated community, the hospital’s state-of-the-art facility in Berlin, Md. combines old-fashioned personal attention with the latest in technology and services. Atlantic General Health System, its network of more than 25 primary care provider and specialist offices, care for residents and visitors throughout the region. For more information about Atlantic General Hospital, visit

About the CMS Innovation Awards

The Centers for Medicare & Medicaid Services (CMS) issued the Health Care Innovation Awards funding opportunity announcement in November, 2011, seeking to award up to $900 million toward innovative projects that test new payment and service delivery models to deliver high-quality health care services and lower costs. Awards have been made for up to three years through annually renewable cooperative agreements.
CMS received approximately 3,000 applications for the Health Care Innovation Awards, representing many individuals and organizations from across all states, U.S. territories, and the District of Columbia. CMS contracted with an external organization with extensive experience in managing independent grant review processes to administer the award review process to ensure an objective review of each application. For more information, visit