Georgia Patient-Centered Medical Home University

Program Location: 
Atlanta, GA
Number of Practices: 
Payer Type: 
Partner Organizations: 
Georgia Academy of Family Physicians
Discern Consulting
Georgia Academy of Family Physicians

Reported Outcomes


The Georgia Patient-Centered Medical Home (PCMH) University hosts classes, which have guided more than 200 clinicians through the process of being recognized as a National Committee for Quality Assurance (NCQA) medical home.  PCMH University works off the notion that becoming a medical home is a team effort and the responsibility of reaching journey's end does not lie with any one physician. Through it all - workshops, conference calls, consultations, and internal team meetings - teams work tirelessly to transform their practice processes in an effort to make their clinics more accessible for patients.  

PCMH University provides access to the Delta Exchange, an online network that is dedicated to physicians, clinical staff, office staff, and primary care-focused residency programs committed to the PCMH. In addition, the University provides access to monthly in-office working sessions with a practice transformation coach, personalized conference calls with NCQA consultants/experts, team building/organizational management, guidance from an NCQA application expert, and free CME credit.

Payment Model: 

The PCMH University is funded by the Georgia Academy of Family Physicians and Wellcare of Georgia.  In July 2013, WellCare implemented enhanced payment for PCMH recognition  and continued pay-for-performance incentives for Georgia Medicaid providers that integrate PCMH into their practices.  Based on NCQA's PCMH standards, WellCare rewards providers who achieve one or more of these three standards: (1) establishment as a PCMH via NCQA accreditation, (2) providing PCMH services such as enhanced access and care plan oversight, and (3) meeting selected quality metrics.

Fewer ED / Hospital Visits: 
  • A large multi-site practice reported a 15 percent reduction in hospital admissions for its population in its first year of PCMH implementation, accompanied by an increase in primary care visits and revenue.
Improved Health: 
  • A multi-physician practice achieved a 2.6 percent increase, to over 70 percent, in the number of hypertensive patients whose blood pressure was below 140/90.
Other Outcomes: 

Process Improvements:

  • A multi-physician practice reduced the number of female patients who had not had DEXA scans by more than 20 percent.
  • A multi-physician practice reduced the number of patients with COPD who had not had an annual spirometry test by 31 percent.
  • A small practice raised its rate of screening for depression in the elderly from 11% to 56%, having begun using the PHQ-2 at every visit.
  • A solo physician practice saw a 16 percent improvement in female patients who had needed breast cancer screenings.
  • A solo physician practice improved the rate of pneumococcal vaccinations for patients 65 and older by 11.6 percent.
  • A small physician practice achieved a 6 percent improvement in the rate of tobacco cessation counseling to patients who smoke.
Last updated February 2015
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