Patient-Centered Medical Home

What is a Patient-Centered Medical Home?

Our Patient Centered Medical Home (PCMH) Initiative is a program in collaboration with the Massachusetts Executive Office of Health and Human Services.  It is based on a model showing that the quality of care you receive is best when provided by a team, led by your primary care provider, of health care professionals working together with you and your family. We will work with you to make sure all the health care services you need are coordinated.

The patient-centered medical home model encompasses five key elements:

  • Patient-centered: It is relationship-based, focusing on the whole person. Your provider will respect your unique needs, culture, values, and preferences. We recognize that you and your family are important members of your health care team, and will help you learn to manage your own care.
  • Comprehensive care: We are committed to meeting all your physical and behavioral health needs including prevention and wellness, acute care, and chronic care. Your care team works together to ensure the best care possible. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators.
  • Coordinated care: Your team will coordinate your care across all elements of the broader health care system, including specialty care, hospitals, home health care, and community services and supports.
  • Improved access to your Primary Care Team: Our goal is to be as responsive to your medical needs as possible.  
  • Continuous Improvement:  We are committed to ongoing measurement of our progress in improved treatment outcomes and excellent service to you, our patients.  See how we are doing!

Complex Care Management

One way we are supporting our medical home model is through our Complex Care Management Program, funded by Partners HealthCare. This program is designed for patients with multiple and complex chronic diagnoses and mental health issues, or those that have had multiple hospitalizations or emergency room visits, that require extra coordination. A team of nurses and community health workers meet regularly with patients in addition to their primary care visits to educate and support them as they learn to manage their conditions. Please contact us if you or a family member could benefit from this program.