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Atlantic General Hospital Patient Centered Medical Home

  • Need: Ways to reduce hospital admission rates, emergency department visits, and total cost of care while better accommodating patients of the Atlantic General Hospital Corporation.
  • Intervention: The hospital system applied a patient centered medical home care model to their 7 rural outpatient clinics located throughout the Eastern Shore of Maryland and southern Delaware.
  • Results: From the program's care coordination, care transitions, and intervention efforts, AGH saw improvements in quality-of-care processes, service use, and spending.


Promising (About evidence-level criteria)


Atlantic General Hospital (AGH), a not-for-profit community-based healthcare system, was looking for ways to reduce hospital admission rates, emergency department visits, and total cost of care while better accommodating patients. In 2013, they implemented a patient centered medical home (PCMH) care model in their 8 rural clinics located throughout Worcester County in Maryland and Sussex County in southern Delaware.

Atlantic General Hospital logo

Through a medical team trained in care coordination, AGH's PCMH program provides primary care patients with health literacy education, chronic disease management education, and coordination between AGH health services as well as assistance with transitioning from hospital to home.

The care coordination team is made up of AGH primary care providers, registered nurses, and a program director. In addition, support is provided through a collaborative approach with the local health department that provides a registered nurse, social worker, and community health outreach worker. The team received motivational interviewing training to improve their ability to engage patients with medical treatment. This team-based approached to patient care has helped AGH apply preventive, holistic healthcare.

Atlantic General Hospital partnered with the Worcester County Health Department (WCHD) in Maryland to implement the PCMH model. For their innovative healthcare delivery model, AGH received a 2012-2015 Centers for Medicare & Medicaid Services (CMS) Health Care Innovation Award (HCIA). Their PCMH program is supported by AGH's health IT and community education and outreach program.

Services offered

Care Coordination/Remote Patient Monitoring/Chronic Disease Management Care:

Coordinators receive referrals from a variety of healthcare disciplines, including emergency departments and hospital-based case managers, primary care physicians, and community providers.

Patients are contacted and screened for eligibility and may be enrolled in a number of programs, including:

  • Dedicated Care Coordination – AGH patients are assigned a registered nurse who works with the patient, family, and primary care physician to address medical and psychosocial needs. Interactions are performed via phone, in-person with the physician, or by remote patient monitoring. If a patient is accepted into this program:
    • Patients' medical conditions are reviewed, health goals established, and care plans made.
    • Care coordinators continue monitoring patients, attend primary care office appointments, and make weekly check-in calls.
    • Patients with a diagnosis or chronic condition that require regular medical care in the home are referred to the Worcester County Health Department.
    • For those patients meeting eligibility, Medicare is billed for chronic disease management services.
  • Remote Patient Monitoring – Provides patients with various chronic diseases technology to support them in their home environment for a period of at least 90 days. Patients receive equipment to access the system daily to perform their assessment. Their information is recorded and uploaded to a monitoring station so that a PCMH nurse care coordinator can perform virtual follow-up assessments.
  • Chronic Disease Management – Links patients with chronic diseases to a variety of programs in the region for support so they can function at their optimal level.

Care Transitions:

  • For patients linked to an AGH primary care physician, a nurse calls a patient within 48 hours after discharge from an acute hospital setting to review discharge instructions, schedule a follow-up visit, and ask about adherence to medications and treatment plans.
  • Calls continue once a week within a 30-day time period.
  • The patient's primary care provider is notified if the patient is at high risk for readmission, and a follow-up appointment is completed.
  • For those patients meeting eligibility, Medicare is billed for Transitional Care Management services.


AGH conducted an evaluation of the PCMH with consent from the 1,002 patients enrolled in the program. Using data from the care coordination, care transitions, and intervention efforts, they found improvements in quality-of-care processes, service use, and spending (according to the CMS HCIA Year-3 Report):

  • AGH's overall per/member per/month spending are reduced compared to state averages.
  • Lower inpatient admissions compared to state, with a risk adjusted readmission rate of 9.3%
  • The percentage of inpatient admission followed by an ambulatory care visit with a primary care physician or specialist within 14 days of their hospital discharge increased by 9.5%.

Several positive discoveries were made throughout the evaluation process:

  • Through timely and thorough care coordination, care transitions, and intervention, rural healthcare systems that have limited technology can have a positive impact on their patient population.
  • The benefit of having one hospital serving multiple clinics is that the care coordinator could access patient discharge information quickly to make a post-discharge call within 72 hours.
  • The PCMH model allowed patients to receive follow-up care at their local primary care clinic instead of traveling to the hospital or another designated clinic within the healthcare system.
  • The model worked well for this Maryland hospital system because of the state's 2014 adoption of the global budget system, which offers strong incentive for hospitals to attempt to reduce hospital admission rates.

Atlanta General Hospital's PCMH model is featured in the following publication:

In addition to the HCIA award, below are other awards and recognitions received by AGH for their PCMH model:


Below are several difficulties AGH encountered during the trial period and continuation of their program:

  • Within the 30-day trial period, there was a high numbers of unplanned hospital readmission rates, due to data collection errors.
  • The technological infrastructure fractured communication between electronic medical records and patient databases, making data retrieval a frustrating process. Staff resorted to pulling information by hand, which was cumbersome and time-consuming.
  • Patient barriers like low literacy rates, income level, lack of caregiver support, and limited access to transportation sometimes hindered patients' ability to comply with post-discharge plans.
  • Because a smaller number of the AGH clinics participated, it was difficult to define a credible comparison group from the claims data. Therefore, much of the impact evaluation focus was on the program's care transitions and not the care coordination or intervention efforts.


Below are several replications strategies others can use when creating a similar program:

  • Train a nurse who is already familiar with your system to be your care coordinator and manage transition services. Designate a staff member to serve as the program manager to oversee the daily responsibilities of the program. Bring on a data specialist to manage the data collection process and offer technological support.
  • Stay persistent with data collection as it can be crucial for program growth. Track measures and monitor outcome trends through the data collected to improve patient care quality.
  • Build relationships with surrounding healthcare systems in order to provide better transition care to incoming patients coming from outside facilities.
  • To enhance care coordination efforts between team members, work on building comradery and communication. Hold regular team meetings to coordinate, problem solve, and plan.

Atlantic General Hospital's 2020 Vision for Care Coordination outlines their long-term goals for the program.

Contact Information

Charles Gizara, Director of Care Integration
Atlantic General Hospital

Medical homes

States served
Delaware, Maryland

Date added
September 19, 2017

Date updated or reviewed
August 1, 2022

Suggested citation: Rural Health Information Hub, 2022. Atlantic General Hospital Patient Centered Medical Home [online]. Rural Health Information Hub. Available at: [Accessed 20 February 2024]

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.