How It Works

HCIA has engaged TransforMED®, a subsidiary of the American Academy of Family Physicians (AAFP), to work closely with each participating primary care practice to assess its culture, patient experiences, employee satisfaction, operational model, strategic goals, and technological capabilities. Over the course of 18-24 months, TransforMED® and clinical leadership teams will develop and implement a customized plan to guide the clinic’s transformation successfully into the Patient-Centered Medical Home (PCMH) model.



  • Better Health—The PCMH model results in better outcomes, including reduced mortality, fewer preventable hospital admissions, and improved care plan compliance.
  • Better Care—PCMHs deliver comprehensive, coordinated services that support patient self-care and improve care customization, quality, workflow, and safety.
  • Lower Cost—The proactive PCMH model reduces per-patient costs and avoidable hospital re-admissions, while improving practice profitability through increased efficiency and improved employee satisfaction.



How does it help?

  • Valuing Primary Care—A Johns Hopkins literature review found that in the US, the overall cost of care was 33% lower for adults who had a primary care physician (as opposed to those who did not).
  • Improving Outcome—Having a primary care physician (and having enough primary care physicians available to serve a community) is consistently associated with improved health outcomes for conditions like cancer, heart disease and stroke.
  • Preventing Deaths—In the US, an increase of even one primary care physician in an area, is associated with 1.44 fewer deaths per 10,000 persons.
  • Transforming Health Care—Since 2005, TransforMED® has guided transformation efforts in 677 primary care practices, while supporting 12,445 providers and clinicians, and touching the lives of more than 25 million patients.
  • Increasing Satisfaction—On average, practices that have utilized TransforMED® facilitation services, have seen employee satisfaction increase by 66%, leading to lower employee turnover rates.
  • Boosting Availability—Practices that have implemented a team-based care model, have achieved a 30% increase in same-day availability, on average.
  • Achieving Excellence—89% of practices that have utilized TransforMED® facilitation, have achieved Level III NCQA recognition.
  • Reducing Costs—PCMHs invovled in TransforMED® facilitation programs have saved upwards of $8-32 per patient per month on healthcare costs.



Establishing a ‘Medical Neighborhood’

A well-functioning medical neighborhood allows for the effective flow of information across care facilities, and between clinicians and patients. The focus is centered around patients, with a balance between evidence-based care and patient preferences.


Patient-Centered Medical Homes (PCMHs) function as the core of a medical neighborhood, playing a key role in facilitating care coordination, developing inter-professional care teams, developing individualized care plans for complex patients, and maintaining connections with community-based services for referral and follow-up.