Patient Centered Medical Home


Patient and Family-Centered Care

The Patient Centered Medical Home (PCMH) is a team-based model built around the premise that the best health care begins with a strong primary care foundation.

PCMH improves the care our patients receive by offering enhanced access to care and increased Primary Care Manager continuity, and by promoting patient- and family-centered evidence-based health care.
Patient Centered Medical Homes allow providers and patients to take a more proactive approach to health care, with a stronger focus on prevention. The medical home can reduce the percentage of specialty referrals and result in a PCMH team providing the needed care in one visit. 
The Patient Centered Medical Home model allows for better coordination of care and improved communication among team members and beneficiaries, while placing emphasis on preventive care and chronic care management, and empowering, patients to participate in their care plan.


How Do I Get Care?

There are multiple ways to receive care in the way that works best for you.
We have learned from our experience and listening to you, that both face-to-face and non-face-to-face encounters (virtual care) are needed.
Although some medical needs require an appointment, many things can be more conveniently coordinated using technology.

Face to face appointments: You can schedule an appointment for a same day issue or in the future with your PCM. Although we want to maximize your appointments with your PCM, if you need to be seen during a time when your provider isn't available, we'll get you in to see one of the providers on your team.

Army Medicine Secure Messaging Service (AMSMS) allows you to directly contact your team through the web. Through this service, patients can initiate a web visit consultation, receive preventive care reminders, send a note to the provider’s office, request test results, and ask for prescription renewals. See your Medical Home team to get enrolled in secure messaging.

Tricare Online Allows you to schedule an appointment, review laboratory results, and view health education material.


What members are included in my PCMH medical team?

PCMH team members include a Primary Care Manager (PCM) — a physician, physician assistant or nurse practitioner — as well as a nurse, medic, medical support assistant (clerk), clinical pharmacist, case manager, and registered dietician.


How does the medical home work?

  • You will be notified of your team assignment and dedicated Primary Care Manager’s name, as well as clinic hours, contact information and more.
  • Your team will have appointments available to meet your needs. You can also reach your team by phone, and through secure e-mail.
  • Your team will assist in coordinating specialty appointments. In PCMH, specialists are called medical home neighbors — your team will track your results and keep you up to date.
  • Your health information will be documented in an electronic medical record to ensure all team members and specialists have convenient access to your medical information.
  • Your team will provide you with self-care health information, and will assist you with early recognition of potential health problems and prevention of chronic disease.


What is my role as a member of the team?

Partner with your team by taking an active role in your care.

  • Talk with your health care team, ask questions and share your successes and the concerns in taking care of your health.
  • Keep your team informed of all health care visits to specialists, dentists and emergency rooms (ER), and let them know if you are admitted to the hospital.
  • Let your team know how they are doing, in person or by completing surveys.
  • Make sure you understand your plan of care. Remember, you are in charge of your health
  • Work with your team to maintain or meet your optimum level of wellness.
  • Communicate with your team.
  • Tell them what medications you are taking.
  • Speak up — tell your team what is not working well and what is causing problems.
  • Make sure your contact information is up to date in our system.


How will the PCMH team help me prepare for my appointment?

  • The team will make sure you are able to see your PCM or a member of the team at each visit.
  • Providers will review your medical records prior to the visit and make sure test results and specialty reports are available during your visit.
  • The team will coordinate care with specialists if needed.
  • Your provider may offer education on wellness and health promotion and remind you of visits and age-appropriate wellness screenings.
  • The team may be able to meet your needs over the phone or online through secure messaging instead of having you come into the clinic unnecessarily. We value your time.
  • Your team is able to provide a list of your current medications and written education materials.
  • Your providers may also remind you of military health care readiness requirements such as Exceptional Family Member Program (EFMP) enrolment and required physicals.