Atlantic General Health System's Patient Centered Medical Home Receives Outstanding Rural Health Program Award
Atlantic General Health System’s (AGHS) Patient Centered Medical
Home (PCMH) recently received the 2013 Outstanding Rural Health Program
Award, an honor bestowed annually by the Maryland Rural Health Association.
This award is given to an organization that promotes and provides effective
community-oriented rural health care delivery and excels in service to
One of the goals of the AGHS Patient Centered Medical Home is to reduce
hospital admission rates and emergency department visits. The participating
medical home practices do this by providing their patients with a team-based
approach to care to ensure that all treatment plans, whether they come
from a patient’s primary care provider, a specialist, a rehab center
or other care provider, work together for the best outcome for the patient.
And, almost more importantly, they work to ensure patients understand
their doctors’ recommendations, any prescribed medications, and
how to manage their chronic diseases.
Since the patient centered medical home was expanded to include all of
Atlantic General Health System’s primary care practices as well
as inpatient discharge management from Atlantic General Hospital in January,
hospital admission rates and emergency department visits for those participating
patients have been reduced significantly. If the patients did need emergency
treatment or inpatient care, the cost of that visit has dropped significantly
from pre-PCMH enrollment.
“We’re proud to be the recipient of the Maryland Rural Health
Program Award,” said Michelle Clifton, PCMH program coordinator.
“It’s a testament to the strides our team is making in improving
the health status of many of our patients who have chronic medical conditions.
We will continue to expand our efforts to reach more individuals and further
reduce readmissions and overutilization of the ER. This is the future
of healthcare – to keep people well and out of the hospital unless
they absolutely need those services.”
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 first efforts to implement a patient centered medical home model within
Atlantic General Health System began in 2011, with two primary care practices
entering into a three-year pilot program through the Maryland Health Care
These two practices were the first on the Eastern Shore to receive formal
recognition from NCQA, the designated PCMH review body for the state of
Maryland in February 2012. Through a $1.1 million grant from the Centers
for Medicaid and Medicare Services, Atlantic General Health System was
able to extend this program and it benefits to patients in all seven of
their primary care offices in the region. The program also includes a
transition in care/readmission prevention team and a faith based medical
home "Vision of the Possible," which will be the recipients
of computers in fifteen centers of worship to expand access to electronic
In all, more than 7,000 patients in Worcester and Sussex counties are
part of this coordinated care delivery and health management model.
The PCMH 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. For more information about Atlantic General Health System’s
Patient Centered Medical Home, visit www.atlanticgeneral.org/pcmh.