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Concordance Healthcare Solutions Resources

Care Coordination in Community Health Centers


Since 1967, the American Academy of Pediatrics has been working on the concept of the medical home. Initially introduced for children, the concept has now evolved into one where every patient should have a medical home.

The concept grew out of the realization that many patients were not receiving the best care, especially those who were under-insured. Treatment was fragmented and health workers dealing with a specific issue were often unaware of other related health issues.

The Medical Home Concept

Under the medical home concept, all medical care is coordinated through the patient's medical home. In this way, all aspects of their medical condition are understood and treatments for various conditions are organized and coordinated. When it's necessary for patients to obtain help from the wider medical community, the medical home coordinates this care.

A key characteristic of the patient-centered medical home (PCMH) is a care team led by the patient's primary physician. This team is responsible for providing across-the-board care for the patient, including:

  • Monitoring the patient's overall health
  • Ensuring timely preventive care
  • Providing of care for chronic conditions

Benefits of the PCMH

Although there's a lot of work required to set up a PCMH, there are several benefits:

  • Patient Satisfaction: Due to the implementation of the patient-centered approach, patients are happier with the quality of care they receive and feel that their needs are being met and that they are respected.
  • Comprehensive Care: Patients don't need to seek treatment elsewhere for different conditions because all medical care is arranged and coordinated through the medical home.
  • Continuity of Care: Long-term patient care is improved and potentially serious conditions are treated before they become chronic.
  • Accessibility: Patients have better access to services. Because of the team approach, waiting times are shorter.
  • Alignment with Triple Aim: The PCMH program aligns with the Triple Aim goals of improving patient experience and population healthcare while reducing healthcare expenditure.
  • Merit-based Incentive Payments: Adoption of a PCMH program helps practices adapt to the Merit-Based Incentive Payments and Alternative Payment Models of healthcare.

Community Health Centers: A Natural Fit as the Medical Home

Community health centers already provide a wide range of services to patients. In addition to the provision of primary healthcare, they generally include services such as dental treatment, pediatrics and behavioral health services. Federally qualified health centers generally provide population health management services to the communities they support.

Care Coordination and Cost Reduction

Providing more comprehensive care coordination and reducing the cost of care do not have to be mutually exclusive endeavors. Contact us today to speak to our Community Health Team Experts at Concordance Healthcare to learn more.


eBook: Using Leadn and Six Sigma to Reduce Waste in Your CHC