Skip to main content
Rural Health Information Hub

Formerly the
Rural Assistance Center

Examples of PCMH Programs

To help primary care practices function as medical homes for Medicaid enrollees, there are state-supported community health teams who provide an array of services in selected states. Community health teams are comprised of multidisciplinary staff working in partnership with primary care practices to connect patients, providers, and systems through care coordination. As of July 2012, eight states provided funding for community health teams: Alabama, Maine, Minnesota, Montana, New York, North Carolina, Oklahoma, and Vermont. Early data from the Commonwealth Fund suggests that community health teams can help to reduce costs, improve quality, and increase capacity in smaller primary care practices.

A rural care coordination program in southeast Nebraska formed a consortium to implement a PCMH model that involves case management with persons using the emergency room for non-emergent care and persons who have not been compliant with their care. In this program, a local public health department serves as a community-based case management provider, working in close partnerships with the hospitals in the community. A similar model was implemented in Lincoln, Nebraska through Lincoln E.D. Connections Program, which utilizes case managers to help chronically ill patients identify a medical home 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, 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
Toolkit
This document describes the medical home 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

Care Management for Medicaid Enrollees through Community Health Teams
Report
An overview of community health team programs in eight states that provide an array of targeted services, from care coordination to self-management coaching.
Organization(s): The Commonwealth Fund
Author(s): Takach, M. & Buxbaum. J.
Date: 5/2013

Care Transitions for Patients Experiencing Homelessness
Webinar
This webinar provides an introduction to transitional care and highlights a new care transition model developed by Oregon Health and Sciences University that targets low-income and uninsured patients, including those who are experiencing homelessness.
Organization(s): National Health Care for the Homeless Council
Date: 10/2012

A C lose Look at Care Coordination within Patient-Centered Medical Homes: West Virginia’s Experience
Webinar
This webinar explores West Virginia’s patient-centered medical home program.
Organization(s): Agency for Healthcare Research and Quality
Date: 5/2013

Initial Lessons from the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home
Evaluation
This paper, published in the Annals of Family Medicine, explores the key factors in successful in transforming primary care practices into patient-centered medical homes.
Author(s): Nutting, P., Miller, M., Crabtree, B., Jaen, C.R., Stewart, E., & Stange, K.
Date: 5/2009

Integrating Behavioral Health & Primary Care for People Experiencing Homelessness
Webinar
This webinar discusses how two healthcare for the homeless projects have implemented integrated behavioral health and primary care models and what factors have contributed to their successes.
Organization(s): National Health Care for the Homeless Council
Date: 2/2013

Leading Transformation to a Patient-Centered Medical Home
Webinar
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 Practice-Based Care Coordination: A Workbook
This workbook includes the tools and supports needed for a primary care practice to develop their capacity to offer a pediatric care coordination service; particularly for children with special healthcare needs.
Organization(s): Center for Medical Home Improvement (CMHI)
Author(s): McAllister, J., Presler, E., & Cooley, W.C.
Date: 6/2007

Medical Home Tool Kit
Toolkit
This website is designed to help providers in Tennessee transition to being patient-centered medical homes, however many of the resources are applicable to primary care providers from all states.
Organization(s): Tennessee Department of Health

Optimizing Health Care for LGBT People in Patient-Centered Medical Homes
Webinar
This webinar explores why obtaining information on sexual orientation and gender identity is important to population health and patient-centered medical homes.
Organization(s): National Health Care for the Homeless Council
Date: 8/2012

Patient Centered Medical Home Case Study Featuring Mary Howard Health Center
Webinar
This webinar discusses the NCQA’s PCMH standards and how they relate to an HCH grantee, the role of outreach staff and a trans-disciplinary team in securing level 3 PCMH certification, and resources to help in preparing for the 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
Webinar
Yakima Neighborhood Health Services, a member of the Council and a 330 funded HCH program, shares its journey as the first community health center in Washington State to achieve Level 3 NCQA recognition.
Organization(s): National Health Care for the Homeless Council
Date: 11/2011

Patient-Centered Primary Care Collaborative Webinars
Website
Website archives webinars produced by the Patient-Centered Primary Care Collaborative on a range of patient-centered medical home-related topics.
Organization(s): Patient-Centered Primary Care Collaborative

A Selective List of National Medical Home Web Sites and Resources
Resources
This document provides a list of resources on subjects related to patient-centered medical homes, including information on different programs and HIT resources.
Organization(s): Medical Home News
Date: 5/2009