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 care provider.

  • 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 improvement.
  • 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 resources.
  • It should support adoption and use of health information technology for quality improvement;
  • 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 quality improvements.

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.