By Michele Mercer, RN, MSHSA

In our DY2, Q4 Update, I began to introduce the concept of the “Patient Centered Medical Neighborhood” (PCMN) as an emerging priority for the Millennium Clinical Integration Team.

The Agency for Healthcare Research and Quality (AHRQ) articulates that a successful “Medical Neighborhood” will “focus on meeting the needs of the individual patient, but also incorporate aspects of population health and overall community health needs.”

The “Medical Neighborhood” is defined as a clinical-community partnership that includes the medical and social supports necessary to enhance health, with the PCMH practice serving as the patient’s primary “hub” and coordinator of health care delivery.

In specific, the “Patient Centered Medical Neighborhood” expands beyond the concept of Patient Centered Medical Home (PCMH) by integrating high-functioning primary care practices with its “Medical Neighbors” including Ambulatory, Behavioral Health, Acute, and Post-Acute care providers; along with Community-Based health care, and non-clinical community-based partners such as Community-Based Organizations (CBOs), schools, and public health agencies, to name a few.

As the “hub” of the “Medical Neighborhood”, the high-functioning PCMH strives to collaborate with these various “Medical Neighbors” to encourage the flow of information across and between clinicians and patients, to include specialists, hospitals, home health, long term care, and other clinical providers. In addition, non-clinical partners such as community centers, faith-based organizations, schools, and public health agencies are also integrated.

Together, these organizations can actively promote care coordination, fitness, healthy behaviors, proper nutrition, as well as healthy environments and workplaces. Their collective goals are specific and measurable and include:

  • Improved Care Coordination.
  • Improved Patient Safety.
  • Improved Patient Experience.
  • Reduced Duplication and Waste.
  • Improved Outcomes.
  • Reduced Costs.
  • Improved Population Health Management.


Millennium Deliverables

As we move into DY3, the Millennium Clinical Integration Team will increase efforts with our Partner PCMH practices to implement collaborative Patient-Centered Medical Neighborhoods, including focusing on establishing:

  • Effective Care Coordination linkages.
  • Inter-connectivity (i.e. HeL and Cerner Population Health Tool).
  • Strong bi-directional communication process along patient care touch-points.

Specifically, MCC Clinical Integration staff will help achieve these objectives by focusing on providing support to key PCMH personnel/roles as follows:

RN Care Coordinator:

  • Establish clinical care management coordination.
  • Provide self-management support coordination.
  • Ensure patients are scheduled for services and follow-up with patients to ensure services were received.


  • Establish Medication Reconciliation program.
  • Establish Medication Adherence program.
    • The above includes, providing medication information, education, and related self-management support
  • Provide medication consultations.

Social Worker:

  • Focus on social determinants of health.
  • Establish assessment of patients’ social needs and referral process to required social service organizations.
  • Assess and address barriers to self-management.

It’s been said “it takes a village to raise a child.” In similar sentiment, the best, most forward focused care will be provided to the patient by her or his “Medical Neighborhood.” We look forward to working with you to make this concept an abundant reality across Western New York.



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The Erie County Medical Center Corporation (ECMCC) is the parent organization of Millennium Collaborative Care

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