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.
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.
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
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.
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
- 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
- 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.
- 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
- 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
- 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
Atlanta General Hospital's PCMH model is featured in the
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
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.
September 19, 2017
Date updated or reviewed
August 1, 2022
Suggested citation: Rural Health Information Hub,
Atlantic General Hospital Patient Centered Medical Home [online]. Rural Health Information Hub. Available at:
[Accessed 20 February 2024]
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