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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.

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

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

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