The Patient-Centered Medical Home (PCMH) is a care delivery model that ensures coordinated patient treatment through primary care physicians (PCPs). This is a care delivery model where the primary care physician is the lead decision maker, and the specialist recognizes the primary care physician as such. This model emphasizes treating patients using a whole person’s approach, addressing their physical, social, and behavioral needs while meeting the patient's highest level of experience of care. The PCMH-Neighbor (PCMH-N) model extends this approach by integrating specialists, sub-specialists, and behavioral health providers into a collaborative care system with PCPs. The PCMH/PCMH-N model aims to:

• Strengthen the role of the PCP in delivering and coordinating healthcare.
• Support population health management through targeted interventions that reduce illness and healthcare utilization.
• Improve communication, coordination, and integration between PCPs and specialists, ensuring appropriate information flow and clearly defined roles.

GMP Network Support for PCMH Designation

• Dedicated GMP Coordinator: Provides on-site or virtual support based on practice preference, meeting at least quarterly to guide PCMH progress.
• Quality & Utilization Data: Offers insight into practice performance metrics to help identify and prioritize areas for improvement.
• Templates & Binder Development: GMP staff assist in building PCMH binders and supply templates to support workflow and policy development aligned with PCMH capabilities.
• Care Management Team: Our team includes specialists in chronic disease management, behavioral health, and social determinants of health to support participation in PDCM initiatives.