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February's Quality Improvement Grantee Spotlight

“Vermont’s Community Health Centers of the Rutland Region Use of the Patient Centered Medical Home Model to  Provide Coordinated Patient Centered Care”

Community Health Center of the Rutland Region logo


This month the Health Resources and Services Administration’s (HRSA) Quality Improvement website highlights Vermont’s Community Health Centers of the Rutland Region (CHCRR) and describes their use of the patient center medical home (PCMH) model to improve health outcomes and coordinate care for patients. CHCRR uses a comprehensive health care team to help its patients avoid unnecessary hospitalizations and to prevent them from receiving fragmented care. This spotlight describes key components of CHCRR’s use of the PCMH model and explains how it has transformed their delivery of  primary care to patients. In addition, this spotlight describes how CHCRR uses health information technology and patient data to enable their PCMH to coordinate and deliver high quality patient centered care to better serve their patient population.

What is a Patient Centered Medical Home?

The concept of a PCMH is to provide accessible, comprehensive, coordinated primary care emphasizing a team based approach, while improving healthcare quality and positive patient health outcomes.  To reach this goal, a PCMH facilitates partnerships among physicians, clinical staff, individual patients, and their family. Patient care is transformed and realigned through the use of registries, information technology, health information exchange and other means to assure that patients receive the indicated care when and where they need it in a culturally and linguistically appropriate manner.

While the concept of a PCMH is not new (it was first introduced by the American Academy of Pediatrics exit disclaimer  in 1967), it currently receives a great level of attention as a central part of broader health reform efforts underway. Also, as the federal overseer of the health center primary care system, the HRSA’s Bureau of Primary Healthcare  (BPHC) established a goal  that 25% of all health centers have at least one site recognized as a PCMH by 2013.  BPHC also encourages and supports all health centers to receive National Council of Quality Assurance’s exit disclaimer (NCQA) PCMH  recognition.

About Community Health Centers of the Rutland Region

CHCRR is based in Rutland, Vermont, exit disclaimer a midsize rural city with a population of 17,292 people, located in the central western part of the state.  CHCRR operates three additional Vermont health centers located in rural communities of Brandon, Castleton and West Pawlet. In addition to patients from Vermont, CHCRR also serves patients from neighboring rural regions of New York State. CHCRR coordinates specialty and tertiary patient care with Rutland Regional Medical Center, the area’s largest inpatient provider. CHCRR offers a full range of services including preventative medicine, women’s health care, well-child care including immunizations, management of chronic or serious illness, minor office procedures, and dental care. CHCRR is a Level 3 NCQA  accredited PCMH and has fully implemented an electronic health record (EHR) system throughout its health centers. CHCRR’s EHR allows staff to coordinate and integrate a patient’s care and adjust their treatment plan based upon current patient data, clinical protocols, and a patient’s care history.

How the PCMH Model Benefits CHCRR and Its Patient Population

A main strength of a health center based PCMH, such as CHCRR provides coordinated patient centered care focusing on the healthcare needs of its patient population. CHCRR’s patient population includes a mix of urban and rural patients, most of whom suffer from at least one chronic disease. Through targeting the chronic diseases specific to their patient population, CHCRR was able to transform how they deliver primary care services, train staff, and realign resources and programs that work together to meet a patient’s health care needs. CHRCC’s Medical Director describes the value of the PCMH model in helping their health center meet the health care needs of their patient population. Dr. Brad Berryhill states, “The PCMH is a structural means to align the health center’s organizational strategic perspectives with the most critical and pertinent needs of our patients.”  The PCMH model helped strategically align CHCRR’s health care priorities and resources, transforming CHCRR into a high quality coordinated primary care system, targeting the healthcare needs of their patient population.

How Does Coordinated and Patience Centered Care Benefits CHCRR’s Patient with Chronic Diseases?

An example of how CHCRR’s PCMH effectively coordinates treatment and meets their patient’s health care needs is illustrated in their work with patients diagnosed with atrial fibulation; a chronic disease with a high incidence rate in CHCRR’s patient population. Atrial fibrillat ion is the most common form of heart arrhythmia and is generally treated with an anticoagulation drug or blood thinner, such as Coumadin. According to the FDA, Coumadin can interact dangerously with commonly used medications and specific foods.  Patients treated with this drug must be on a restricted diet or else they might suffer from blood hemorrhages or blood clots. CHCRR coordinates patient centered care for those prescribed Coumdain to help them avoid hospitalizations or experience adverse health events.
CHCRR patients treated for atrial fibulation with Coumadin benefit greatly from a PCMH’s ability to not only coordinate care, but also use patient data collected through CHCRR’s EHR to enable patient centered care. Atrial fibulation patients prescribed this drug, require frequent checkups in order to closely monitor and adjust their Coumadin doses. For example, each time a CHCRR patient prescribed Coumadin visits their clinical care team, the EHR displays a clinical protocol checklist (PDF - 75 KB) specific to that patient. This checklist is derived from an evidenced based clinical protocol (PDF - 191 KB) developed by CHCRR staff  based on patient data and peer reviewed resources. The check list indicates to the care team what specific tests, such as blood pressure and glucose, are needed for that visit. Demonstrated in the EHR screen shot below, the EHR captures a patient’s updated lab and test information, as well as a patient’s vital signs. The EHR also displays to the patient’s care team what tests are complete or overdue.  Each time a test or vital sign is entered into the system, CHCRR staff  has the necessary information to determine the next steps in a patient’s treatment. The ability for patients who are prescribed Coumdain to have their care coordinated based on specific patient data, enables CHCRR’s comprehensive care team to determine the best treatment options.

CHCRR Patient Guideline Explorer EHR chart screet

Using Patient Data To Coordinate the Patient’s Care

Having the ability to view this patient information allows a patient’s care team to coordinate or adjust the patient’s next treatment steps. After each visit, the patient discuses these next treatment steps with members of their care team, such as a care coordinator. For example, if a patient’s tests indicate their eating habits might be causing a complication in their Coumadin regiments, the CHCRR care coordinator will then send the patient to a dietitian or a specialized patient education group for additional treatment. After this consultation, the patient is provided an updated patient centered management plan (PDF - 149 KB) to learn how they should care for themselves until their next visit. If necessary the care coordinator will also call the patient to follow up on any questions and to ensure they are adhering to their patient centered management plan. The availability of up-to-date and accurate patient information allows the care coordinator and CHCRR staff to coordinate and work together in the best interests of each patient.  


In utilizing the PCMH model in their health center, CHCRR has increased the positive health outcomes of their patient population, as well as increasing patient satisfaction. A CHCRR patient explains his satisfaction and the improvement in his health as a result of CHCRR’s PCMH ability to coordinate and provide patient centered care. Mr. C states,

“I have a great doctor and his nurse always goes above and beyond to help me.  He {My doctor} has done an excellent job helping me with my blood pressure and has given me a Plan of Care that I keep on my refrigerator.  We set goals, talk about some of my bad habits and identify what I can do better.  About two weeks ago, a nurse from the Clinic called me and reminded me that I need a Lipid Panel.  At first I thought she was wrong as I just had this done.  But as it turned out,  it was over a year ago.  When I came in for my visit last week, the doctor had all of my information reviewed and ready.  It really made me feel great that he had taken that time.  After we met, I went to the pharmacy which is right in the clinic, very convenient.  I had a breathing test and chest X-Ray done right in their Lab/X-Ray dept.  My doctor wants me to meet with their dietician when I get back from vacation.”

CHCRR is a powerful example of how a health center can meet the needs of their patient population and achieve positive health outcomes through the use of the PCMH model’s ability to coordinate patient centered care.

For more Information please email CHCRR's Clinical Director Claudia Courcelle at or visit HRSA's Bureau of Primary Healthcare Patient Center Medical Home, National Council of Quality Assurance’s PCMH Recognition Website.exit disclaimer