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Patient-Centered Medical Home

What is a Patient-Centered Medical Home?

ALTThe Patient-Centered Medical Home (PCMH) is a term that means healthcare provided by your physician, your care team and you working together as a team.   The PCMH is a healthcare setting that facilitates partnerships between individual patients, and their providers, and when appropriate, the patient’s family.

Your personal care  team may include: Primary Care Physicians, Specialty Physicians, Community Based Providers, Nurse Practitioners, Physician Assistants, Nurses, Medical Assistants, Behavioral Health Specialists, Social Workers, Care Coordinators, Pharmacists, etc. Because the whole team is familiar with you and your medical history, they can also address many of the concerns and questions you have about your health care needs.


All 18 adult and pediatric primary care Baystate Medical Practices have been officially recognized as Patient-Centered Medical Homes. 

What will this mean for me?


  • Team-based care - Your doctor will lead the team of nurse practitioners, nurses, medical assistants, specialists and other caregivers — who will work with you to meet all of your health care needs.  They will offer consistent, coordinated care and communication, and will help arrange for specialty care whenever you need it.


  • Improved health care access and communication - We will make every effort to see you on the same day. You should call your provider’s office number during working hours to schedule a same-day appointment with us. Many urgent health care needs, including cuts, earaches, colds and fevers can be handled by your Patient Centered Medical Home team. If for any reason we are unable to see you on the same day, we will refer you to one of our Urgent Care facilities.


Benefits for you:

  • You will see a familiar face at every appointment —a member of your caregiver team.
  • Your doctor and the other doctors on your team will be able to spend more quality time with you.
  • If you are hospitalized at a Baystate Health hospital, your team will contact you within 48 hours of discharge to answer any questions. If you go to a hospital outside Baystate Health, we ask you to notify them upon admission so they can contact your hospital team to coordinate care.
  • Once you are discharged, your team will ensure that your recovery is progressing as planned to prevent readmission. They will also identify appropriate specialists you may need to see.
  •  We will help you make sure that all tests, procedures, and specialist appointments are scheduled in a way that best meets your health care needs. 
  •  We will respect you and your family values and needs, respect your culture and use language you understand, help you set health goals and create an action plan. We will track your care from all providers and explain test results and offer support services when needed.
  • Improved quality - Quality and safety are hallmarks of the medical home and are promoted through such practices as having patients actively involved in decision making, using evidence-based medicine and clinical decision-support tools to guide decision making, and expecting physicians in the practice to be accountable for continuous quality improvement.
  • Together with your care team we will help coordinate a self-managed health care plan for chronic conditions.
  • Access to educational materials and resources to help patients manage their health on a day-to-day basis.

What do I have to do?


  • Talk openly with your team about all your healthcare questions.  If you have any questions or concerns about your care plan, tell your team about it and work together to make changes if needed.
  •  Let your medical team know if you see any other healthcare provider and if you do, remind him/her to forward reports to us.
  • Bring a list of all your healthcare questions and medications to your appointment.


How do I learn more about the Patient-Centered Medical Home? 

The following websites provide more detailed information about the Patient Centered Medical Home and its benefits to patients.