Patient-Centered Medical Home (PCMH)

What is PCMH ?


Patient-Centered Medical Home


PCMH is a model of health care where patients have a direct relationship with a provider who coordinates a cooperative team of health care professionals, takes collective responsibility for the care provided to the patient and arranges for appropriate care with other qualified providers as needed. It strives to provide superior health care at an affordable price.


The medical home is intended to result in more personalized, coordinated, effective and efficient care. A medical home achieves these goals through a high level of accessibility, providing excellent communication among patients, clinicians and staff and taking full advantage of the latest information technology to prescribe, communicate, track test results, obtain clinical support information and monitor performance.



PCMH criteria can be categorized as follows:


  • Enhance Access and Continuity: Accommodate patient needs with access and advice during and after hours, give patients and their families information about their medical home and provide patients with team-based care
  • Identify and Manage Patient Populations: Collect and use data for population management
  • Plan and Manage Care: Use evidence-based guidelines for preventive, acute and chronic care management, including medication management
  • Provide Self-Care Support and Community Resources: Assist patients and their families in self-care management with information, tools and resources
  • Track and Coordinate Care: Track and coordinate tests, referrals and transitions of care
  • Measure and Improve Performance: Use performance and patient experience data for continuous quality improvement


What does this mean for our patients and their families?


  • More information collected: Our patient information sheet will be expanded to collect more demographic information, such as ethnicity and preferred language.
  • Surveys: Periodic surveys of performance will be collected to identify strengths and weaknesses of our team.
  • Tracking: Identification, management and outcomes of specific health problems will be tracked without patient identification to allow patient privacy.
  •  Best care! Be secure in knowing that our clinicians will continue to provide up to date evidence based care in a cost effective manner.


The American Academy of Family Physicians (AAFP) presents the following video detailing PCMH.

Phone: 703-573-2432

Fax: 703-280-9350




Fairfax Office


Prosperity Plaza

3020 Hamaker Ct.

Suite 200

Fairfax, VA 22031

Phone: (703) 573-2432

Fax: (703) 280-9350


Herndon Office


Reston/Herndon Center

131 Elden St.

Suite 312

Herndon, VA 20170

Phone: (703) 573-2432

Fax: (703) 280-9350


Great Falls Office


737 Walker Road

Suite 4

Great Falls, VA 22066-2833

Phone: (703) 573-2432

Fax: (703) 280-9350


South Riding Office


25055 Riding Plaza

Suite 290

South Riding, VA 20152

Phone: (703) 573-2432

Fax: (703) 280-9350