Patient Centered Medical Home (PCMH) & Neighborhood (PCMH-N):

The Patient-Centered Medical Home (PCMH) is a care delivery model in which patient treatment is coordinated through primary care physicians to ensure patients receive the necessary care when and where they need it, in a manner they can understand. The PCMH-Neighbor model enables specialists and sub-specialists, including behavioral health providers, to collaborate and coordinate with primary care physicians to create highly functioning systems of care. The goal is to deliver effective and efficient care across all practice settings.


  • Improve the quality and efficiency of care
  • Improve the physician-patient relationship
  • Increase patient satisfaction
  • Ensure effective communication and information
  • Provide appropriate and timely referrals

Organized System of Care (OSC)

The aim is to provide a community of caregivers partnering to create an organized system of care.  The purpose of this system is to identify the patient population (through and integrated registry; Wellcentive), measure performance, share information across the system and support process improvement.  This community includes:

  • Primary care physicians
  • Specialists
  • Hospitals
  • Laboratories
  • Pharmacies
  • Urgent Care

Increasingly, and already true with some payers, financial results for hospitals, specialists and primary care physicians will be driven by performance measured at the population, or OSC, level.

Differences between an OSC and an Accountable Care Organization (ACO)

Conceptually OSC’s and ACO’s are aligned in that both are provider organizations functioning to improve clinical outcomes and lower cost measured at the population level.  However an OSC focuses on “before the fact” responsibility such as supporting infrastructure, and an ACO focuses on “after the fact” accountability with population-level performance and contracts that link payment to that performance.