A central component of the PCMH model is coordination of care across clinicians, organizations, and institutions beyond the primary care office. The Patient Centered Medical Neighborhood (PCM-N) is described below by the Agency for Healthcare Research and Quality (AHRQ).
Many of the goals of the PCMH rely on improved communication and coordination between and across health care providers and institutions: in other words, they require a high-functioning medical neighborhood that (1) encourages the flow of information across and between clinicians and patients, and (2) introduces some level of accountability to ensure that clinicians readily participate in that information exchange. Given that its locus is squarely within the primary care settings of the health system, and the fact that many patients require a substantial amount of specialty care, the PCMH alone can do only so much in creating and promoting the functioning of the medical neighborhood. Thus, specialists, hospitals, other providers, health plans, and other stakeholders also play key roles in ensuring a close-knit neighborhood.
The AHRQ Patient Centered Medical Home Resource Center provides links to multiple practical guides for PCM-N development
The MacColl Institute resources on Care Coordination and the Chronic Care Model provide tools for improving care coordination across the provider system in the context of the Chronic Care Model.
The AHRQ Pathways Model describes specific applications of the pathways model and provides tools for developing pathways projects.