All 12 PCMH initiatives are open to all specialists. We encourage physicians to discuss the role of affiliated specialists in PCMH initiatives. These roles may vary depending on the specialty and characteristics of the patients served by the PO.

  • Patient Registry – This encourages PGIP participants to establish a comprehensive patient registry that they can use to manage their patients, improve patient health status and ultimately lower health care costs.
  • Test Tracking and Follow Up – This aims to help practices implement a standardized, reliable system to ensure that patients receive needed tests, timely results and appropriate follow up care. This also helps practices to properly document each step in the test tracking process.
  • Coordination of Care – This coordinates patient care across the health system through collaboration and communication among providers, caregivers and the patient.
  • Web Portal – This supports optimal management of patients with chronic conditions. Patients use a web portal for electronic communication with their physicians. They also get greater access to medical information and technical tools.
  • Specialist Referral Process – This focuses on coordinating patient referrals from primary care to specialty care. Both providers receive timely access to the information they need to provide the best care to the patient.

Physician specialty focus: All primary care physicians and specialists participating in PGIP