Patient Center Medical Home

Patient-Centered is a way of saying that you, the patient, are the most important person in the health care system. You are the center of your healthcare.

A Medical Home is an approach that yields both better healthcare care and lower costs. With your Medical Home, you are joining a team that provides centralized, comprehensive, coordinated primary care and cultivates partnerships between patients, their personal physicians, the care giving team, and the patient's family.

A Patient-Centered Medical Home is a Partnership between the patient and their physician.


Our Patient Centered Medical Home (PCMH) model of patient care emphasizes quality of care and monitoring of outcomes. We routinely evaluate our performance in specific areas and compare with national benchmarks of quality. Below are some examples of recent quality improvement (QI) initiatives in our office: 

Measure #1 Generic versus Brand name prescriptions

During the measurement period of 5/1/2015 to 8/1/2015, 4% of the prescriptions ordered were brand name drugs. Our goal was to decrease the number by half. During the re-measurement period of 2/6/2016 to 5/6/2016, the percent of brand name drugs prescribed decreased to 2%.

Measurement #2 Percentage of women over the age of 40 receiving screening Mammograms

We found during the first measurement period 5/1/2015 to 8/1/2015, 16% of the women over 40 had documented Mammogram results. Our goal was to bring this percentage up to 50%. During the re-measurement period of 3/1/2016 to 5/1/2016 the percentage was calculated at 51%, and increase of 35%. 

Measurement #3 Colorectal screening

During the first measurement period 5/1/2015 to 8/1/2015 we determined 15% of our patients between the ages of 50-80 had current documented Colorectal screening results. Our goal was to increase this number to 40%. During the re-measurement period of 3/1/2016 to 5/1/2016 we found that we exceeded this goal and reached 48%, an improvement of 33%.


Being a part of a PCMH, your doctor will:

  • Work with you to improve your health
  • Review your medications at every visit and discuss with you any interactions or contraindications
  • Develop a personal action plan with you to address your chronic conditions
  • Set goals with you and monitor your progress
  • Use computer technology to monitor your progress and determine if your health is improving
  • Inform you of all test results
  • Help you take control of your health by providing you educational material, hosting group visits and linking you to other community programs and resources
  • Provide you 24 hours access to a clinical decision-maker by phone
  • Have arrangements for after-hours care and be informed of your visit or emergent treatment within 24 hours or next business day
  • Reserve space in our schedule for you to accommodate a same-day appointment
  • Refer you to available community resources when the need arises

By choosing to participate in a PCMH, I agree to:

  • Make sure my doctor knows my entire medical history
  • Tell my doctor all of the medications I am taking
  • Actively participate with my doctor in planning my care
  • Keep my appointments as scheduled
  • Adhere to the action plan designed by my doctors
  • Consult my doctor before making my own appointment with a specialist
  • Request that any other doctor I see, send my doctor a report including copies of lab work, test results, and any x-rays
  • Know my insurance and what it covers
  • Provide the office feedback on how they can improve
  • Contact Primary Care Doctor’s office for after-hours urgent, non-emergent conditions


    Frequently Asked Questions

    What can I expect as a patient?

    You will have access to a single point of comprehensive care that addresses the full range of your healthcare needs. Your care will be guided by your Primary Care Physician who will work closely with other members of your medical team. You will share in making decisions regarding your care, and you and your doctor will create a health care plan designed to help you achieve optimum wellness.

    How will my office visit change?

  1. You will be educated with tools that explain the concept of Patient-Centered Medical Home, which will outline your rights and responsibilities.
  2. Medication review and management will be provided at every visit.
  3. You and your healthcare provider will work together on goal setting and action plans to help ensure your unique guidelines are followed.

Additional Information

  1. You will have access to a doctor on call 24 hours-a-day, 7 days-a-week.
  2. All care provided will be geared to help you accomplish your personal health goals.

How will I benefit as a patient?

    Patients who choose to receive care through the PCMH model will benefit by the following: access to doctors who utilize improved technologies to stay better connected with the medical community and manage care more efficiently; more focused, personal interaction with doctors and care teams who navigate through the complex healthcare system; a more compr ehensive delivery of primary care through the improved coordination of care, managed by the patient's personal doctor and their care team.