The Patient Centered Medical Home/ Patient Centered Medical Home-Neighborhood is a model in which all patient care is coordinated between the Primary Care Physician (PCP), Specialists and any other healthcare provider with the patient's well-being in mind. This means coordinating necessary care if and when they need it and reducing unnecessary or redundant care when they don't. 


The PCMH/PCMH-N model drives office workflow to coordinate care between all health care professionals with effective communication, defined roles and responsibilities between providers and patients and supportive interventions in order to better population health management, quality, outcomes and cost. 




Where do I start?

Contact us!

Call or Email any one of our PCMH team members and we can get you started with a PCMH/PCMH-N starter kit, including a Binder for you start working on as well as a tutorial through your roles and expectations for the program.

The PCMH/PCMH-N program can not only improve your quality, outcomes and cost of care for your patients, but may also yield financial incentives from entities such as Blue Cross Blue Shield of Michigan. However this means that we also require some intitiative from your practice as well. For OPNS, we require attendence of at least half of the Workgroups that we offer throughout each year as well as implementation of 1-2 new Capabilities for Specialists and 2-3 new Capabilities for Primary Care Physicians.


Although OPNS cannot recommend a specific service to you, the below chart has been drafted using vedors most frequently used within our network, along with some information that might help you with your process.

Use of any non-HIPAA compliant telehealth platforms will be accepted for reimbursement for most health plans indefinitely

Telehealth Codes

This, as well as additional information, will also be found under each health plan listed on our website, just follow the steps below:

  1. Head to the top-right corner of the website and click Login (if you have not logged in already)
  2. Once you have logged in, hover over Practice Resources listed in the top bar of the website and click on any of the listed health plans
    • Any information provided by the health plans will be listed, dated and named regarding their contents, including telehealth information





Click below for the most current information available under each health plan on approved telehealth codes:

Blue Cross Blue Shield of Michigan / Blue Care Network and PDCM and Additional Coding Guidance

BCBSM/BCN Using Telehealth to Close Gaps in Care

HAP Medicaid (also includes MDHHS codes that may be applicable to other Medicaid plans!)

HAP Behavioral Health / Medicare / Commercial



Priority Health and Priority Health Telemedicine website

United Healthcare



What Resources can OPNS provide for me? 

Work Groups

These may be required for participation in our program, but they can also provide you with supplemental information on the PCMH/PCMH-N Capabilities. How to implement them in your office, what Capabilties apply to your practice or Specialty, how to write a policy or how to prove a Capabilitity as well as a unique opportunity to get away from the office just to work solely on your PCMH/PCMH-N Binder.

Aren't in a Work Group yet? We have different groups (same agenda) for different days of the week to accomodate schedules, just let us know which Work Group you would like to be in and we will add you to the list:

Just contact us if you need us to come out for individual visits for binder help and engagement.

GROUP 1: Tuesdays @ 9:30am

01/17/2023    02/014/2023    03/14/2023    04/18/2023    05/16/2023     07/18/2023    08/15/2023    09/19/2023    10/17/2023      11/14/2023


GROUP 2: Wednesdays @ 9:30am

01/18/2023    02/15/2023    03/15/2023    04/19/2023    05/17/2023     07/19/2023    08/16/2023    09/20/2023    10/18/2023    11/15/2023


GROUP 3: Wednesdays @ 1:00pm

01/18/2023    02/15/2023    03/15/2023    04/19/2023    05/17/2023     07/19/2023    08/16/2023    09/20/2023    10/18/2023    11/15/2023


GROUP 4: Thursdays @1:00pm

01/19/2023    02/16/2023    03/16/2023    04/20/2023    05/18/2023     07/20/2023    08/17/2023    09/21/2023    10/19/2023    11/16/2023


GROUP 5: Fridays @ 8:30am

01/20/2023    02/17/2023    03/17/2023    04/21/2023    05/19/2023     07/21/2023  08/18/2023    09/22/2023    10/20/2023    11/17/2023



We also offer a short 30min introductory to Self-management techniques offered by our Lead RN Care Manager here at OPNS; this also fulfills the criteria for any Self-Management Capability that you have in place and is required to be redone annually.

Currently these are only offered on a Friday @ 11:00am:



Does your Binder have all of this? Click on any one and get a copy for your Binder

Urgent Care Brochure Page 1

Urgent Care Brochure Page 2

Training Log

Red Book of Community Resources

Health Leads Social Determinants of Health

2022-2023 Interpretive Guidelines by BCBSM

PCMH-N Relevancy Grid by BCBSM

PCMH/PCMH-N Policy Templates

Domain 1     Domain 2     Domain 3     Domain 4     Domain 5     

Domain 6    Domain 8     Domain 9    Domain 10    Domain 11   

Domain 12    Domain 13    Domain 14

Do you have an OPNS provided, customized Patient Provider Partnership Brochure? 

Take a look at our example; if you are interested just email us your office information: location(s), hours and after hours information and we can make you your very own PPP brochure to hand out to patients in your office.


PPP Pic.jpg


Satisfaction Survey Process

OPNS has been working on the patient satisfaction survey process, which covers PCMH/PCMH-N capabilities 4.4, 11.4 and 14.9.  As Pfizer will no longer be providing this service, OPNS has found a way to utilize Survey Monkey for all Practices. 


OPNS has established individual practice links for patients to access the survey.  This can be done by giving the patients the link on a Business card, sending the link to patients by text or mass email to all patients. OPNS is also able to loan a pre-loaded laptop with access to the survey, if needed, for 2 weeks to complete the surveys.  With completion of a minimum of 50 patients, OPNS can run and send an office level report on the findings.


If interested, please contact us to begin working on a Survey Monkey that will be specific to your practice.

2021 Mid Year Cycle Review: Maintained PCMH Designated Practices

Recognizing the Designated Practices for all their efforts!


Recognized Specialist Practices

A list of our amazing PCMH-N Recognition for the dedicated work from our Specialist practices!