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Rural Health Information Hub

Formerly the
Rural Assistance Center

Examples of PCMH Programs

Rural program examples of patient-centered medical homes (PCMHs) are provided below. For additional rural PCMH program examples, see Module 7: Program Clearinghouse.

  • State Medicaid Medical Home Programs: Several states have PCMHs that provide services to Medicaid enrollees. The PCMHs include community health teams that are comprised of multidisciplinary staff working in partnership with primary care practices to connect patients, providers, and systems through care coordination. Early data suggests that community health teams can help to reduce costs, improve quality, and increase capacity in smaller primary care practices.
  • Lincoln E.D. Connections Program: Utilizes case managers to help chronically ill patients identify a PCMH and other needed community resources.
  • Community Care of North Carolina (CCNC): Sponsored by the North Carolina Department of Health and Human Services and the North Carolina Division of Medical Assistance, CCNC is implementing a PCMH model. CCNC helps 14 regional networks in North Carolina to implement care improvement initiatives for Medicaid and underserved populations. CCNC has extended care into rural communities by connecting providers and community organizations in North Carolina's 100 counties.
  • Accountable Care Organizations may use the PCMH model in their primary care practices.

For important considerations when implementing a PCMH model, see Module 3: Implementation.

Resources to Learn More

Behavioral Health Homes for People with Mental Health & Substance Use Conditions: The Core Clinical Features
Document
This toolkit describes the PCMH model developed by the SAMHSA-HRSA Center for Integrated Health Solutions, focusing on integrating mental health and primary care providers.
Organization(s): SAMHSA-HRSA Center for Integrated Health Solutions
Date: 5/2012

A Close Look at Care Coordination within Patient-Centered Medical Homes: West Virginia’s Experience
Video/Multimedia
Webinar and PowerPoint slides that explore care coordination efforts in West Virginia, including adoption of elements of the PCMH.
Organization(s): Agency for Healthcare Research and Quality
Date: 5/2013

Community Care Teams: An Overview of State Approaches
Document
This white paper describes community health teams (also called community care teams), which support the PCMH, and provides several state examples.
Organization(s): Center for Health Care Strategies (CHCS) and the State Health Access Data Assistance Center (SHADAC)
Date: 3/2016

Leading Transformation to a Patient-Centered Medical Home
Video/Multimedia
In this webinar, Columbus Neighborhood Health Center shares its experience and strategies related to its level 3 NCQA PCMH recognition in 2011. Presentations and recordings are both available.
Organization(s): National Health Care for the Homeless Council
Date: 11/2012

Medical Home Tool Kit
Website
This toolkit presents PCMH information and resources for both families and healthcare providers. The information was developed for providers in Tennessee but is applicable to other states.
Organization(s): Tennessee Department of Health

Optimizing Health Care for LGBT People in Patient-Centered Medical Homes
Video/Multimedia
This webinar explores the importance of obtaining information on sexual orientation and gender identity for population health and the PCMH.
Organization(s): National Health Care for the Homeless Council
Date: 8/2012

Patient Centered Medical Home Case Study Featuring Mary Howard Health Center
Video/Multimedia
This webinar presents a case study of a nurse-managed health center and discusses PCMH standards, the role of outreach staff, and resources to support PCMH evaluation.
Organization(s): National Health Care for the Homeless Council
Date: 12/2011

Patient Centered Medical Home Case Study featuring Yakima Neighborhood Health Services
Video/Multimedia
This webinar presents a case study on Yakima Neighborhood Health Services, the first community health center in Washington State to be recognized as a Level 3 PCMH by NCQA.
Organization(s): National Health Care for the Homeless Council
Date: 11/2011

Patient-Centered Primary Care Collaborative Webinars
Website
A collection of webinars that discuss a range of PCMH topics.
Organization(s): Patient-Centered Primary Care Collaborative

A Selective List of National Medical Home Web Sites and Resources
Documents
This document provides a list of websites and resources for PCMHs, including information on different programs and HIT resources.
Organization(s): Medical Home News
Date: 5/2009