Patient-Centered Medical Home


NCQA ’s Patient-Centered Medical Home (PCMH) is an innovative program for improving primary care. In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time.

How it works

PCMH facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

Summit Participation in PCMH

Summit’s PCMH program ranks in the top 10, among such healthcare powerhouses as Kaiser Permanente, Carolinas Health Systems and Novant Medical Group.

PCMH results in more personalized, coordinated, effective and efficient care in a healthcare delivery model that revolves around the patient. Summit practice sites and physicians have long succeeded in providing high quality health care. PCMH finally provides the support and resources to physicians, sites and patients to create a better patient experience with improved efficiency and outcomes.

Summit had to meet six areas of criteria in order to receive PCMH certification. Criteria included:

  • Enhancing access and continuity of care
  • Accommodating needs after hours
  • Identifying and managing care
  • Providing self-care support and community resources
  • Tracking and coordinating care
  • Measuring and improving performance​


Learn about Care Coordination and how it relates to Summit's participation in PCMH.   Click Here.

An Example of how it works 

An example of how PCMH works in improving a patient’s overall health and health care experience is explained in the following example:

A mid 40s male patient visits his Summit Medical Group primary care physician and has a history of high blood pressure, weight gain and high cholesterol. The patient has as hectic lifestyle, filled with fast food and a generally high fat diet and is discouraged because he can’t lose weight or decrease his blood pressure. The primary care physician holds the key to increasing the patient’s life span and helping him get on the right path to good health.

Instead of just writing a prescription and saying, “see you in six months,” the Summit physician instead provides extra attention and education because of PCMH. The physician schedules time for the patient to meet with a care management coordinator every six weeks who recommends that the patient keep a daily food diary. The care coordinator also works with the physician to set up group education classes, which are free to the patient and offered through Summit’s Health Education Division. With the help and support of the care coordinator, a checks and balance system in place and the patient gradually begins to lose weight and see improvements in health numbers. After six months with the care coordinator, the patient returns to the physician and the numbers prove that the program is working and a healthy lifestyle is now reality.

PCMH is just one more way Summit is remaining the trusted health care provider in East Tennessee – working with the patient, provider and insurer to complete the circle of care.