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.

What Resources can OPNS provide for me? 

27Work 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

01/21/2020    02/11/2020    03/10/2020    04/07/2020    05/05/2020    08/11/2020    09/08/2020    10/13/2020    11/17/2020


GROUP 2: Wednesdays @ 9:30am

01/22/2020    02/12/2020    03/11/2020    04/08/2020    05/13/2020    08/12/2020    09/09/2020    10/14/2020    11/18/2020


GROUP 3: Wednesdays @ 1:00pm

01/22/2020    02/12/2020    03/11/2020    04/08/2020    05/06/2020    08/12/2020    09/09/2020    10/14/2020    11/18/2020


GROUP 4: Thursdays @1:00pm

01/23/2020    02/13/2020    03/12/2020    04/09/2020    05/07/2020    08/13/2020    09/10/2020    10/15/2020    11/19/2020


GROUP 5: Fridays @ 8:30am

01/24/2020    02/14/2020    03/13/2020    04/10/2020    05/08/2020    08/14/2020    09/11/2020    10/16/2020     11/20/2020



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:

03/27/2020     04/10/2020     05/08/2020


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

Urgent Care Brochure

Red Book of Community Resources

Health Leads Social Determinants of Health

2019-2020 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.

2019 PCMH Designated Practices

Recognizing the Designated Practices for all their efforts!


2019 Recognized Specialist Practices

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