Patient Centered Medical Homes


Asian man holding his grandson. Older latino man in graduate cap and gown with his wife. Woman in wheel chair playing piano with her partner turning pages. Collage of health care managers ineracting with patients.FY2012 marked the beginning of the PCC’s three-year CareFirst BlueCross BlueShield-funded project to assist two Montgomery Cares participating clinics (Holy Cross Health Center and Proyecto Salud) in transforming their practices to Patient-Centered Medical Homes (PCMH). The Montgomery Cares Patient Centered Medical Home (MC-PCMH) Collaborative Pilot is focused on improving health outcomes for patients with multiple chronic conditions by applying a model based on the principles of PCMH. Our pilot sites are:

  • Enhancing and expanding care management capabilities
  • Engaging patients and families in the care process
  • Facilitating communication among patients, families, and providers across systems of care

A Patient Centered Medical Home (PCMH) is more than just a clinic. It is a model of organizing and delivering primary health care that is:

Patient-centered—revolves around the patient and is focused on the whole person integrating cultural values, family considerations, unique preferences, and individual motivations for wellness.

Comprehensivemeets most of the patients physical and behavioral health needs through a team-based approach.

Coordinated—synchronizes all aspects of patient care across the health care system such as specialty care, hospitals, and community-based support.

Accessible—minimizes wait times for appointments and uses alternative methods of communication so patients can easily contact their care coordinator.

High quality—provides safe, evidence-based care through shared decision-making and performance measurement.

In a PCMH, care management is the job of everyone on the care team and professional care is integrated with self-management. This project supported a dedicated RN Care Coordinator to help establish and support a plan of care for the most medically and socially complex patients in the clinics. Each enrolled patient has a care plan and a patient action plan to guide the care to be provided by health professionals as well as the self-care steps that the patient will take to reach his or her wellness goals.