Table 3.

Key PCMH Components in highlighted PCMH demonstration projects

Demonstration	Results	Key PCMH Components
Geisinger Health System (Pennsylvania)	18% reduction in inpatient stays and 36% reduction in readmissions (39) Reduced ESRD (23)	Advanced EHR with patient and physician tracking and communication Personal Health Navigator: care coordination and follow-up Evidence-based care plans with Nurse Care Coordinator services
HealthPartners (Minnesota)	Cost savings and reduced hospitalizations and ER visits (42) Improved diabetes and cardiovascular measures (20) Improved patient satisfaction (41)	Enhanced communication mechanisms between providers and patients Electronic registry management Family-centered care plans Care coordination
Pennsylvania Chronic Care Initiative (Southern Pennsylvania)	Improvement in diabetes and cardiovascular risk factors (4, 43) Increased preventive measures and appointments including screening, self-management, eye and foot exams, vaccination rates, smoking cessation, and preventive medication use (24, 43)	Care managers and practice coaches for coordination Quality reporting Electronic registry management Team-based structure with strong leadership and staff learning collaborative
Group Health Cooperative (Seattle, WA)	Improved quality measures Reduction in hospitalizations and ER visits Cost-savings Improved patient and provider satisfaction (44, 45)	Team model with higher proportions of non-physician staff Longer appointment times Online patient portals Enhanced communication and follow-up Increased patient access to physicians