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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 rural people.

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 Commission.

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 health information.

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