Medical Home Shows Results

Atlantic General Hospital (AGH), a not-for-profit community-based healthcare system has implemented a Patient-Centered Medical Home (PCMH) in seven rural clinics located in Worcester County in Maryland and Sussex County in southern Delaware.

The PCMH’s medical team trained in care coordination provides primary care patients with health literacy education, chronic disease management education, and helps patients with AGH health services, as well as provide help to patients transitioning from hospital to home.

The care coordination team is made up of AGH primary care providers, registered nurses, and a program director. In addition, support is provided using a collaborative approach with local health departments able to provide registered nurses, social workers, plus community health outreach workers.

AGH evaluated the PCMH with consent from the 1.002 patients enrolled in the program. Using data from the care coordinators they found:

  • AGH’s overall spending was reduced by 30.8 percent or $1,333 per beneficiary every month
  • Outpatient ED visits and inpatient admission rates decreased by an average of 14.7 percent


It was also found that the percentage of inpatient admissions followed by an ambulatory care visit with a primary care physician or specialist within 14 days of the hospital discharge increased by 8.8 percent. However, this was better than the unrelated emergency room visits that had become increasingly common.

It was found that using timely and thorough care coordination, care transitions, and intervention, enabled rural healthcare systems with limited technology to have a positive impact on their patient population.

AGH also found that within a 30 day trial period, there was a high number of unplanned hospital readmission rates due to data collection errors. The fractured communication between EMRs and patient data bases made data retrieval a frustrating process.

To improve the effective use of available technology, the AGH Health System established a partnership with Allscripts as the primary vendor for clinical systems throughout the hospital and physician offices.

The hospital system found in feedback sessions that the ability for system integration with actionable information to use for clinical decision-making is a key weakness. They found that if the hospital is not efficient in care delivery, then very often entry information needs to be duplicated. Also, weakness in the use of technology to deliver information makes it difficult to transfer care from one level to another and increases the risk of errors.

AGH in looking to the future use of technology sees the need for a centralized data repository and the need for data to be integrated with financial and clinical systems, the necessity to deploy EMRs in all clinical areas, and the need to enable patient information to flow from one level of care to another.

Email Charles Gizara, AGH Director of Care Integration, at for more information.

Share Button