Patient Centered Medical Home
What is a Patient Centered Medical Home?
A 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. PCMH utilizes teamwork
and information technology to improve care and patient outcomes/experiences
all while reducing costs. The PCMH team is structured to provide for all
patient healthcare needs or work with other healthcare professionals to
meet those needs.
What the PCMH Provides to You
If your primary care provider refers you to Atlantic General's Patient
Centered Medical Home (PCMH), you will be contacted by one of our care
coordinators who will begin to help you navigate the healthcare system
and assist you on a path to better health.
Your PCMH care coordinator will be monitoring your medical needs and will
contact you to schedule any needed follow-up appointments with your primary
Your PCMH team will help coordinate any appointments needed with a specialist
or another health agency. We will help you in making sure that all tests,
procedures, and specialist appointments are scheduled in a way that best
meets your health care needs.
In order for us to provide our best primary care services, please let your
care coordinator or primary care provider know if you see any other health
care provider. Also, please remind any health care provider that you may
see to forward reports to us regarding your condition and treatment. This
will allow us to best coordinate your clinical care.
Working together, we can understand your health risks, if any, and take
care of them before they become more serious problems. If you have any
questions about your PCMH care plan, please call your care coordinator
or the PCMH main line at 410-641-9949,
History of PCMH
Atlantic General Hospital launched its PCMH model in 2011, with two primary
care practices entering into a three-year pilot through the Maryland Health
Care Commission. These two practices were the first on the Eastern Shore
to receive formal recognition from NCQA, the designated PCMH review body
for the stated of MD in Feb 2012.
Later in 2012, the PCMH program was a recipient of a $1.1 Million grant
from the Centers for Medicaid and Medicare Services, which allowed us
to extend services to all of Atlantic General Health System's primary
care offices in Berlin, Ocean City, Ocean Pines, Snow Hill, Pocomoke,
Ocean View and West Fenwick.
Current Status 2015
We have extended our program to included diabetes care coordination, and
we have worked to increase communication with long-term care facilities
that provide rehab services to patients discharged from Atlantic General
Hospital. Three care coordinators are available to patients who participate
in PCMH between 8 am and 4:30 pm, Monday through Friday. These care coordinators
work closely with our patients, AGHS primary care providers (family practice
and internal medicine), therapy providers and other specialists involved
in patients' care. The aim of PCMH is to increase healthy literacy and
awareness of chronic conditions through education, resulting in improved
self-care and self-management.
PCMH is a recipient of National Committee for Quality Assurance (NCQA)
level 2 recognition for AGHS primary care offices. NCQA is an independent,
non-profit organization dedicated to assessing and reporting on the quality
of managed care plans.
“NCQA raises the bar in defining high-quality care by emphasizing
access, health information technology and coordinated care focused on
patients,” NCQA President Margaret E O’Kane. To earn this designation the PCMH
team had to demonstrate the ability to meet the programs key elements,
embodying characteristics of the medical home. NCQA standards align with
joint principles of the PCMH established by the American College of Physicians,
the American Academy of Family Physicians, The American Academy of Pediatrics
and the American Osteopathic Association.
There are six standards of effective PCMH Care:
- Enhance access and continuity
- Identify and manage patient populations
- Plan and manage care
- Provide self-care support and community resources
- Track and coordinate care
- Measure and improve performance
The overarching goal of the PCMH is to improve individuals' health and
wellness to reduce community hospital admission rates and emergency room
visits. Our participating medical home practices do this by providing
patients with a team-based approach to care ensuring that all treatment
plans, whether they come from a patient’s primary care provider,
a specialist, a rehab center or other care providers, work together for
the best outcome for the patient. We work to ensure patients understand
their doctors’ recommendations, any prescribed medications, and
how to manage their chronic diseases.
The PCMH model has been developed to address inefficiencies in the current
fragmented healthcare system in the United States. 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 duplicate
testing and less than optimal management of chronic conditions.
The PCMH focuses on a preventive, holistic approach and brings the various
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 specialist 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.
Quality & Safety are the Hallmarks of PCMH
- Practices advocate for their patients to support the attainment of optimal,
patient-centered outcomes that are defined by a care planning process
driven by a compassionate, robust partnership between physicians, patients,
and the patient’s family.
- Evidence-based medicine and clinical decision-support tools guide decision making
- Physicians in the practice accept accountability for continuous quality
improvement through voluntary engagement in performance measurement and
- Patients actively participate in decision-making and feedback is sought
to ensure patients’ expectations are being met
- Information technology is utilized appropriately to support optimal patient
care, performance measurement, patient education, and enhanced communication
- Practices go through a voluntary recognition process by an appropriate
non-governmental entity to demonstrate that they have the capabilities
to provide patient centered services consistent with the medical home model.
- Patients and families participate in quality improvement activities at
the practice level.
Enhanced access to care is available through systems such as open scheduling, expanded
hours and new options for communication between patients, their personal
physician, and practice staff.
Payment appropriately recognizes the added value provided to patients who have
a patient-centered medical home. The payment structure should be based
on the following framework:
- It should reflect the value of physician and non-physician staff patient-centered
care management work that falls outside of the face-to-face visit.
- It should pay for services associated with coordination of care both within
a given practice and between consultants, ancillary providers, and community
- It should support adoption and use of health information technology for
- It should support provision of enhanced communication access such as secure
e-mail and telephone consultation;
- It should recognize the value of physician work associated with remote
monitoring of clinical data using technology.
- It should allow for separate fee-for-service payments for face-to-face
visits. (Payments for care management services that fall outside of the
face-to-face visit, as described above, should not result in a reduction
in the payments for face-to-face visits).
- It should recognize case mix differences in the patient population being
treated within the practice.
- It should allow physicians to share in savings from reduced hospitalizations
associated with physician-guided care management in the office setting.
- It should allow for additional payments for achieving measurable and continuous
After Normal Office Hours
If you have an urgent medical issue when your provider’s office is
closed, call the office telephone number and follow the instructions given
to reach the on-call provider.
Please continue to call 911 for all emergencies.
For More Information
The following websites provide more detailed information about the Patient
Centered Medical Home and its benefits to patients.