Patient-Centered Medical Home

Imagine A Different Kind of Health Care…

This new model is called the Patient-Centered Medical Home, and it is offered at all of our Community Health Centers.You will be a part of a team made up of providers, medical assistants and health specialists that help coordinate your health care.


What is a Patient Centered Medical Home?

A patient centered medical home is a place where you can go to receive excellent healthcare, from a team of professionals who work with you to ensure that your needs are met, your voice is heard, and your health and well-being is in the center of our practice. In the medical home, care is evidence based, accessible well coordinated and patient focused. Patient satisfaction and quality of care are of the utmost importance. We want you to feel at home and well cared for by your health care team and most importantly we want you to meet your healthcare goals.

How do I choose a primary care provider?

Patients provided with several options in choosing a primary care provider based on personal preference, medical needs and provider expertise and even patients own cultural, ethnic and linguistic expectations. At Neponset Health Center and for adult patients, you have a choice between an internsit or a family provider; for children and adolescent care, you have a choice between pediatrics or family medicine, our OBGYN patients can choose between women’s health and family medicine.  At Geiger Gibson Community Health Center and Harbor Community Health Center-Hyannis, patients have access to Family Medicine practioners and dental professionals. The health center providers are all board certified, with significan expertise and experience in their field of study. Many attended prestigious medical and dental schools and speak mulitple languages. As a medical patient you have the choice between a MD and a Nurse Practitioner.

How is care coordinated across the health center and with outside specialists?

Care coordination begins with your primary care team which consists of you, your provider medical assistant, care manager nurse and your care coordinator. Your team is required to understand you, understand family dynamics, unique needs, your values and preferences, even your cultural orientation and background. Depending on your needs, other members of the team may include clinical pharmacists, nutritionists, specialists, and behavioral health experts. Your primary care team is actively involved in working to provide you with the best care possible by accessing different discplines in the health center and outside. Your care team works closely with local hospitals, off-site specialists and community resources to ensure that we meet the needs of our patients and we provide timely and accurate follow through. Most importantly, the success of the Patient Centered Medical Home model depends on keeping you informed and engaged in your treatment and providing you with the supporters necessary to manage your own health the way it makes sense to you and your family.

How do I get specialty care?

Depending on the health center, we provide our patients with specialty services such as podiatry, optometry, OBGYN, midwifery, infectious disease primary care and case management. For all other specialty care needs, your care team has access to specialty services in the communities we serve.

How do I get involved in my treatment plan?

Engaging you in your treatment planis in the core of Patient Centered Medical Home. We will involve you in a variety of ways: the care team will ask for your input about medical decisions and treatments, will work with you to develop self-management goals and care plans will ask you for feedback in the way of patient satisfactio surveys and focus groups and will provide you with access to resources to supoort your medical care.

How do I get a referral? How does the center ensure that the referral is obtained and report received?

The best way to obtain a referral is to schedule an appointment with your provider so that this can be done in a more informed and efficient manner. After consulting with your provider, a mutual decision is made to refer you for diagnostic testing or specialty care depending on your needs. Your provider will make a referral to the referral team and the referral team will work with your insurance company to ensure that the services you’ve been referred to is approved by your insurance agency and to schedule an appointment.

How do I get a referral? How does the center ensure that the referral is obtained and report received?

You have several options to choose from including making calls to your team, scheduling and appointment to see your provider and have a face to face discussion of any issues that re relevant to you and your treatment, using the patient portal to communicate via secure email. If you are not enrolled in the patient portal, we encourage you to speak with your care team on how to obtain a user name and password. At the end of this packet, you can find instructions on how to access and log in to the patient portal. An on-call provider is available for all patients after hours, weekends and holidays hours. Services, hours of operation and phone numbers for each of our community health centers are provided in the next few pages.



How Can You Be An Active Partner?

Talk to Us

Give us feedback on how our office works. You can even take part in our Patient Focus Groups.

Take Care of Yourself

Set health goals that you are comfortable with and make life choices to meet those targets. Join support groups with people like you and learn how to manage serious illnesses.

Be Safe

Look at different treatment options and compare their risks and benefits. Tell our Clinical Pharmacy Team about any medicines, supplements and herbal or holistic products you take.



Take a look at the Patient-Centered Medical Home Brochure and at your next visit, ask for an Office Guide. This handy resource contains all of your Care Team information and can fold up to fit in your wallet.

Click here for a list of Pain Management Specialists