Resources & Downloads

The PCMH Portal

What is a Patient-Centered Medical Home?

A patient-centered medical home (PCMH) is a more effective and efficient model of health care delivery. This new model produces better care and lower costs. In a patient-centered medical home:

  • Patients have a relationship with a personal physician.
  • A practice-based care team takes collective responsibility for the patient's ongoing care.
  • Care team is responsible for providing and arranging all the patient's health care needs.
  • Patients can expect care that is coordinated across care settings and disciplines.
  • Quality is measured and improved as part of daily work flow.
  • Patients experience enhanced access and communication.
  • Practice uses EHRs, registries, and other clinical support systems.

For a very good overview of the Patient-Centered Medical Home, please visit

To download a copy of the AAFP's Patient-Centered Medical Home checklist, click here.

PCMH Model at work in North Carolina:

Community Care of North Carolina (CCNC)

CCNC is a demonstration program that began in July 1998 and aims to build upon North Carolinas' Primary Care Case Management Program - Carolina Access - by working with community providers to better manage the enrolled Medicaid population.

CCNC is designed to bring together providers to cooperatively plan for meeting patient needs and to strengthen the community health care delivery infrastructure. Providers are expected to take responsibility for managing the care of an enrolled population, to provide preventive services and to develop processes by which at-risk patients can be identified and their care managed before high cost interventions are necessary.

Currently, CCNC provides care to more than 750,000 Medicaid recipients in the state, making the program the largest payer in North Carolina. The program relies heavily on medical homes, population health management, community-based networks and case-management services to deliver care.

The CCNC program is distinguished by the following features: Partnership, a Population Health Management Approach, and Accountability. For more information on CCNC, please visit

Key Transformation Resources & Sites -

AAFP's PCMH Resource Page -

AAFP's Free Webinar Series on PCMH -

Transformed -

The Patient-Centered Primary Care Collaborative -

Community Care of NC's PCMH Toolkit -

Agency for Healthcare Quality & Research PCMH Site -

CCNC's PCMH Recognition Guide -

PCPCC's Practical Guide to Transformation -

The DeltaExchange at TransforMED -

Merck Overview Video of PCMH -

Reports, Articles & Presentations on PCMH -

Trends in Healthcare in NC -

Building Medical Homes: Lessons From Eight States with Emerging Programs -

Medical Home 2.0 -

AHRQ's PCMH Articles Listing (w/citations) -

BCBSNC’s Move Towards the Patient-Centered Medical Home is Helping My Small Family Practice -

Downloadable Resources -

AAFP's Checklist -

Patient Handout by PCPCC -

NCAFP Handout: Value of PCMH -

NCAFP Handout: What a Medical Home Means to You -

Current PCMH Efforts in North Carolina -

Community Care of NC -

Multi-payer Advanced Primary Care Practice Project -

Blue Quality Physician Program at BCBSNC -
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