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? 

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

01/15/2019    02/12/2019    03/19/2019    04/16/2019    05/14/2019    08/13/2019    09/10/2019    10/15/2019    11/12/2019


GROUP 2: Wednesdays @ 9:30am

01/16/2019    02/13/2019    03/20/2019    04/17/2019    05/15/2019    08/14/2019    09/11/2019    10/16/2019    11/13/2019


GROUP 3: Wednesdays @ 1:00pm

01/16/2019    02/13/2019    03/20/2019    04/17/2019    05/15/2019    08/14/2019    09/11/2019    10/16/2019    11/13/2019


GROUP 4: Thursdays @1:00pm

01/17/2019    02/14/2019    03/21/2019    04/18/2019    05/16/2019    08/15/2019    09/12/2019    10/17/2019    11/14/2019


GROUP 5: Fridays @ 8:30am

01/18/2019    02/15/2019    03/22/2019    04/19/2019    05/17/2019    08/16/2019    09/13/2019    10/18/2019    11/15/2019



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:

02/01/2019    03/08/2019    04/12/2019


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

2018-2019 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


2018 PCMH Designated Practices

We would like to recognize the Designated Practices for all their efforts!


2018 Recognized Specialist Practices

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

Words of Wisdom


  • Make sure that your Self-Mangement training is up to date, they must be done yearly


  • Have the most recent Community Resources guide available to all staff and have a systematic process for identifying the needs of patients


  • Be sure to ask about Advanced Care Planning for your patients, there is never a bad time to start planning for the future to ease the burden on the patients and their loved ones


  • Be aware of any changes to the Interpretive Guidelines, including retired and new Capabilities that you may want to put in place