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Research Objective: The Patient-Centered Medical Home (PCMH) has been advocated as a model to address the lack of coordination and continuity in the health system. However, implementation in practice has been slow and incompletely described. Study Design: Patients referred into the program received intensive nurse follow-up focused on medication adherence, care coordination, and education. Patients graduate from the program when treatment goals are met. Population Studied: The first 100 patients enrolled into the PCMH focused program of a primary care clinic in an urban, academic medical center. The main outcome measures are goal adherence and emergency room use. Principal Findings: Ninety percent of enrollees met the health goals set for them at enrollment. During their enrollment, 31.6% of patients with diabetes reduced and maintained their blood glucose readings; 24.6% of patients with hypertension reduced and maintained their blood pressure readings. Emergency department use in the time period following enrollment dropped 46.7%. Conclusions: The ambulatory intensive care unit program showed an improvement in health outcomes and health care use.This program also helps to move the practice toward PCMH by centralizing care through a primary care provider, enhancing access to care, and by focusing on the patient holistically through rapport with a nurse. Implications for Policy, Delivery, or Practice: This care delivery method drives the clinic closer to the PCMH and toward the Accountable Care Organization (ACO) model.

Enhancing Quality of Primary Care Using an Ambulatory ICU to Achieve a Patient- Centered Medical Home