Your Medical Home

Patient-Centered Medical Home (PCMH)

Patient-Centered Medical Home (PCMH) is a primary care delivery model where the patient partners with their care team to coordinate and manage their care. In the PCMH model, the care team uses research based care and the computer to assist with decisions. The patient is involved in planning their care with the care team and to set achievable goals. The care team measures and plans activities for the improvement of care and to meet the patient’s needs. The PCMH model emphasizes patients at medical homes to receive right care at right time. This model improves patient experience, improves access to care, reduces the cost of health care, provides better communication, promotes team based care and improves the quality of care delivered to the patients.

PCMH has six key elements:

  1. Patient-centered Access: Being available to patients when they need to communicate with their provider or health care team. Accommodating patient needs by opening early, having after 5pm hours and opening on Saturdays. Providing 24/7 access to clinical advice via telephone or electronic access.
  2. Team-Based Care:  Care team members working together to offer you the best care possible. The care team is can be made up of Doctors, Physician Assistant, Nurse Practitioner, Nurse Manager, Nurse, Medical Assistant, Nutritionist, Care Managers, and Patient Care Coordinators.
  3. Population Health Management:  Shifting the focus of care towards the whole person by including prevention, wellness and chronic care as well as acute care.
  4. Care Management and Support: Being responsive to your other needs along with your medical needs and supporting you thorough out. Involving you in making care plans and guiding you in self-care.
  5. Care Coordination and Care Transition: Committing to meet all the physical and behavioral health needs and coordinating care across all care services. Examples are but are not limiting to hospitals, specialty care, community services and follow up.
  6. Performance Measurement and Quality Improvement: Maintaining higher standards of quality and a commitment to monitoring our progress so that we can offer an exceptional service to the patients.


Piedmont Health as your Medical Home

As your medical home Piedmont is here to offer you patient centered quality care with a better experience every time you visit us focusing on health of whole person with integrated behavioral health.

Primary Care Providers

As the patient, you can choose your Primary Care Provider (PCP) so that you can build a positive, working relationship with your provider.  You will work with your provider as a team to solve health related issues. How? By seeing the same PCP over the course of time, the provider has the opportunity to become familiar with your family medical history and your medical history. Your PCP will use evidence based guidelines to educate you about your condition and involve you in your care plan and support you on self-management.

Piedmont Health offers quality health care and is staffed by medical professionals that are Board Certified/Board Eligible in:

  • Family Medicine
  • Pediatrics
  • Internal Medicine

Your Care Team

To help with your care, a PCP has a whole Care Team to help you take better care of your health. Each member of the Care Team has an important role in your care. The team may consists of the PCP (may be a physician, nurse practitioner or physician assistant), nurses, medical assistants, nutritionists, personal care assistants and care managers depending on your specific needs. Our care team proactively reaches out to you with the anticipation of your health care needs by keeping you informed and engaged in the care plan.

Care Coordination

Piedmont is responsible for all your health care needs, both physical and behavioral health, and manages your health care with other health professionals. Piedmont Health will work with you every step of the way to help you navigate the health care system as easily as possible, either inside or outside our health system. We connect you to health and community resources including specialist to coordinate the care and follow up with them.

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