Academic Patient-Centered Medical Home Fellowship in Family Medicine

This database is no longer actively maintained and is here for archival purposes only

Organization Type: 
Educational Institution
Program Type: 
Standing Program
Education Level: 
Postgraduate (e.g., residency, fellowship)
Educational Elements: 
Independent Study
Self Reflection Activities
Experiential including clinical contact with patients
Program Description: 

ABOUT THE PCMH FELLOWSHIP The fellowship is a one-year, full-time faculty development fellowship designed to create physician leaders in primary care practice improvement and transformation to PCMH model of care.  West Virginia University Department of Family Medicine has been engaged in practice transformation since January 2012 and works collaboratively with affiliated practices at various stages of PCMH development. The rich academic environment of the department and the institution provides valuable opportunities for experiential learning in practice transformation leadership.

The fellow serves as a member of our interprofessional quality team that includes advanced practice nurse wellness coordinator, nurse case managers and pharmacist.  The quality team develops strategies for high risk vulnerable patients and provides oversight for practice care coordination activities.  The fellow works collaboratively with all members of the care team (nursing, pharmacists, dietitian, social worker, registration and billing staff), providing leadership for quality improvement efforts, workflow redesign and team care strategies.  The fellow provides education to medical students and residents about patient-centered medical home concepts and practice based quality improvement (monthly updates during resident meeting, didactic lectures to students, coaching residents for quality improvement projects).   Every member of the clinical care team participates in one of six Care Improvement Teams for work on practice improvement (consisting of several faculty, a resident at each level, nursing staff, registration staff, quality office representative).  The fellow participates in all the Care Team meetings and assists with each team’s quality improvement projects and population health reports.


  • Acquire skills to develop, evaluate, teach and lead practice improvement.
  • Acquire applicable knowledge and experience regarding PCMH transformation in an active PCMH environment.
  • Acquire expertise regarding primary care practice requirements for attaining NCQA PCMH Recognition.


  • Graduate of an accredited Family Medicine Residency Program, with board eligibility or board certification.
  • Excellent academic and clinical record.
  • Interest in developing skills in healthcare data analytics, clinical team leadership and chronic disease management.

SCHOLARSHIP REQUIREMENTS The Fellow will be required to present at least one presentation (poster or other presentation) related to primary care practice transformation at a national or regional conference. The Fellow will be encouraged to participate in scholarly exchanges about PCMH and primary care redesign including practice improvement workshops and online learning communities such as TransforMED Delta Exchange or Patient Centered Primary Care Collaborative.

Program Results: 

West Virginia School of Medicine Graduate Medical Education Committee has oversight of the fellowship and has approved the structure and curriculum.  The GME committee will periodically review the fellowship outcomes.

Targeted Professions
Family Medicine
Self-Reported Competencies
PCPCC’s Education and Training Task Force identified 16 interprofessional training competencies critical for preparing health professionals for practicing in team-based, coordinated care models such as patient-centered medical homes. Listed below are the self-reported competencies that this program has achieved, which have been organized by the five core features of a medical home as defined by the Agency for Healthcare Research and Quality
Patient-Centered Care Competencies: 
Advocacy for patient-centered integrated care
Cultural sensitivity and competence in culturally appropriate practice
Patient-centered care planning, including collaborative decision-making and patient self-management
Comprehensive Care Competencies: 
Population-based approaches to health care delivery
Coordinated Care Competencies: 
Care coordination for comprehensive care of patient & family in the community
Interprofessionalism & interdisciplinary team collaboration
Team leadership
Quality Care & Safety Competencies: 
Assessment of patient outcomes
Business models for patient-centered integrated care
Evidence-based practice
Quality improvement methods, including assessment of patient-experience for use in practice-based improvement efforts
Accessible Care Competencies: 
Promotion of appropriate access to care (e.g., group appointments, open scheduling)
Last updated December 23, 2014

* Please note: Information contained in this database is self-reported by representatives from each program. It does not represent an exhaustive list of education and training programs and inclusion does not constitute an endorsement from the PCPCC.


Go to top