TransforMED Selects 90 Primary Care Practices in 65 U.S. Cities as Participants in Three-Year, Patient-Centered Medical Neighborhood Pilot Project

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Patient-centered medical home transformation among participating primary care practices aims for better access and coordination of care across the ‘medical neighborhood’ to improve the health of the community at a lower cost.

As a force for positive change, the new PCMH model of primary care is the foundation for team-based medical neighborhoods that will lead the way to improvements in patient experience in subsequent years.

A total of 90 primary care practices allied with 15 health systems in 65 cities across the country have joined a federally supported health care innovation award project of the patient-centered medical neighborhood (PCMN) care model, awardee and national program convener TransforMED announced today.

Participating practices will pilot test TransforMED’s approach to delivering better health, better health care and lower costs using the PCMN model. The PCMN concept connects patient-centered medical home (PCMH) primary care practices with other community-based health care providers to create a more efficient, coordinated health care delivery network that improves care at a lower cost.

TransforMED, a nonprofit subsidiary of the American Academy of Family Physicians, is leading the nationwide PCMN project funded by a three-year, $20.75 million award by the CMS Center for Medicare and Medicaid Innovation (Innovation Center). Joining TransforMED, an expert in PCMH transformation and PCMN development, are project affiliates VHA Inc., a network of not-for-profit hospitals based in Irving, Texas; Phytel, a provider of automated population health management technology based in Dallas; and Cobalt Talon, an analytics services company based in Kansas City, Mo.

Project affiliates will work to support health care providers in each of the 90 participating practices toward the PCMN development project’s quest for improved health outcomes, improved quality of care and reduced costs. TransforMED facilitators will meet with practice leaders in coming months to understand their current processes and identify areas of improvement in the following four areas to attain stated year-three goals:
•Costs. Reduce overall health care costs for Medicare and Medicaid beneficiaries by 4 percent, or $49.5 million, by 2015
•Health. Improve the health of the eligible population as demonstrated by an average of 15 percent – and at least 3 percent improvement – in each selected quality measure by 2015
•Patient experience. A 25 percent improvement in patient experience measures that reflect patient engagement, access and quality by 2015
•Scalability. Demonstrate the ability to scale to additional practices within each community by 2015.

The 90 practices within the 15 health systems participating in the collaborative PCMN project are:

  •     Avera Health, O’Neill, Neb.

o    Avera Medical Group Creighton
o    Avera Medical Group Crofton
o    Avera Medical Group Hartington
o    Avera Medical Group Niobrara
o    Avera Medical Group O’Neill
o    Avera Medical Group Verdigre

  •     Charleston Area Medical Center, Charleston, W.Va.

o    Cabin Creek Health Systems Inc., Dawes
o    CAMC Family Medicine Center, Charleston
o    Charleston Internal Medicine Inc.
o    Womencare Inc., dba FamilyCare Health Center, Scott Depot

  •     Columbus Regional, Columbus, Ind.

o    Columbus Adult Medicine
o    Columbus Family Medicine
o    Columbus Internal Medicine Associates (CIMA)
o    Doctors Park Family Medicine, Columbus
o    Kavelman Family Medicine, Columbus
o    Nashville Family Medicine
o    Rau Family Medicine, Columbus
o    Sandcrest Family Medicine, Columbus

  •     Greater Baltimore Medical Center, Baltimore

o    Chapel View Family Care, Baltimore
o    Family Care Associates, Towson, Md.
o    GBMA Hunt Valley
o    GBMC Internal Medicine Residency, Baltimore
o    Hunt Manor, Phoenix, Md.
o    Jarretsville Family Care
o    Texas Station, Timonium, Md.

  •     Huntsville Hospital, Huntsville, Ala.

o    HH Physician Care – Bailey Cove, Huntsville
o    HH Physician Care – Gurley
o    HH Physician Care – Hampton Cove, Owens Cross Roads
o    HH Physician Care – Huntsville
o    HH Physician Care – Madison
o    UAB Huntsville Family Medicine

  •     INTEGRIS Health, Oklahoma City

o    INTEGRIS Family Care Central, Oklahoma City
o    INTEGRIS Family Care Norman
o    INTEGRIS Family Care South Penn, Oklahoma City
o    INTEGRIS Family Care Southwest, Oklahoma City
o    INTEGRIS Family Care Yukon

  •     Marquette General Health, Marquette, Mich.

o    MMC Kingsford
o    MMC Gladstone
o    Doctors Park Family Physicians, Escanaba
o    Marquette General Family Medicine
o    Portage Health Medical Group University Center, Houghton

  •     North Mississippi Health Services, Tupelo, Miss.

o    Barnes Crossing Medical Clinic, Tupelo
o    Family Care Clinic of Ripley
o    Fulton Medical Clinic
o    Hamilton Medical Clinic
o    IMA – Tupelo
o    Iuka Medical Clinic
o    Pontotoc Medical Clinic

  •     North Shore Physicians Group, Salem, Mass.

o    North Shore Physicians Group – 400 Highland, Salem
o    North Shore Physicians Group – 331 Highland, Salem
o    North Shore Physicians Group – Marblehead
o    North Shore Physicians Group – Lynn
o    North Shore Physicians Group – 192 North Street, Danvers
o    North Shore Physicians Group – 1 Hutchinson Drive, Danvers
o    North Shore Physicians Group – Saugus

  •     Northeast Georgia Health System, Gainesville, Ga.

o    NGPG Braselton Clinic, Hoschton
o    NGPG Cleveland
o    NGPG Dahlonega
o    NGPG Dawsonville
o    NGPG Medical Park I, Gainesville
o    NGPG Thompson Bridge, Oakwood
o    NGPG Chestnut Mountain, Flowery Branch
o    The Longstreet Clinic – Adult Medicine, Gainesville

  •     Novant Health, Winston-Salem, N.C.

o    Family Medical Associates of Lewisville
o    Forsyth Internal Medicine, Winston Salem
o    Kernersville Family Practice
o    Maplewood Family Practice, Winston Salem
o    Medical Associates of Davie, Mocksville
o    Salem Family Practice, Winston Salem

  •     Orlando Health, Orlando, Fla.

o    Medical Interventions of Central Florida, Clermont
o    OHPG Internal Medicine Faculty Practice, Orlando
o    Total Family Care, Clermont
o    Southwest Orlando Family Medicine
o    OHPG – Dr. Phillips Primary Care, Orlando

  •     Owensboro Medical Health System, Owensboro, Ky.

o    MultiCare – Madisonville
o    MultiCare – Ohio County, Beaver Dam
o    MultiCare – Tell City
o    Primary Care Center, Owensboro

  •     Via Christi Health, Wichita, Kan.

o    VCC at Reflection Ridge, Wichita
o    Via Christi Clinic Newton
o    VCC W. 21st, Wichita
o    Via Christi Family Medicine Center 1121 S. Clifton, Wichita
o    Via Christi Family Medicine Center 707 N. Emporia, Wichita
o    WesleyCare Family Medicine Center, Wichita

  •     Western Connecticut Health Network, Danbury, Conn.

o    WCMG – Ridgefield
o    WCMG – Brookfield
o    WCMG – Southbury
o    WCMG – Danbury
o    WCMG – New Fairfield
o    WCMG – New Milford Green, New Milford

"Implementing the PCMH model is critically important for these progressive practices from across the country who are working side by side with us to improve the health of their respective communities by building effective and efficient medical neighborhoods," said Dr. Bruce Bagley, MD, FAAFP, interim president and CEO of TransforMED.

"Participating systems have demonstrated their willingness to transform their practices and connect primary care to acute care hospitals, specialists and other community resources. The context of a well coordinated and connected medical neighborhood will not only give patients the safe, reliable and efficient care they desire, but also will increasingly empower them to manage their health in a proactive way."

"TransforMED will guide practices through every step of the transformation process," added Kristi Bohling-DaMetz, PCMN Innovation Program Director at TransforMED. "As practices’ primary point of contact for the PCMN Health Care Innovation Award, we will ensure each one’s access to subject matter experts and other resources specific to their individual needs."

Initial work will involve scaling respective organizations, and launching key drivers around technology and practice efficiencies that will enable the PCMN project’s long-term cost reduction aims. In turn, these technology and primary care efficiencies in the first six months are expected to start impacting clinical outcomes in the second half of the first year.

"As a force for positive change, the new PCMH model of primary care is the foundation for team-based medical neighborhoods that will lead the way to improvements in patient experience in subsequent years," Bohling-DaMetz said. "We look forward to leading a positive trend that we can share with additional practices within each participating market in the final year of this three-year project."


About TransforMED
The Leawood, Kan.-based TransforMED is a wholly owned subsidiary of the American Academy of Family Physicians. Established in 2005, TransforMED provides ongoing consultation and support to physicians looking to transform their practices to a new model of care that is based on the concept of a Patient-Centered Medical Home. TransforMED is an active member of primary care communities and recognizes and supports the unique value that primary care offers to patients and the health care system. TransforMED shares and supports the idealism and altruism of primary care physicians and the strong commitment to their communities and patients through continuing patient relationships and independent decision making. TransforMED offers practices both products and services, including consultation and advice on implementing the patient centered medical home model. To learn more about TransforMED, visit Follow us on Twitter and find us on Facebook.

About VHA Inc.
Founded in 1977 and based in Irving, Texas, VHA Inc. is a network of not-for-profit hospitals that work together to drive maximum savings in the supply chain arena, set new levels of clinical performance, and identify and implement best practices to improve operational efficiency and clinical outcomes. VHA leverages its expertise in analytics, contracting, consulting and networks to help its members achieve their operational, clinical and financial objectives. In 2011, VHA delivered record savings and value of $1.9 billion to members. VHA serves more than 1,350 hospitals and more than 72,000 non-acute care providers nationwide, coordinating delivery of its programs and services through its 13 regional offices. VHA has been ranked as one of the best places to work in healthcare by Modern Healthcare since the publication introduced this list in 2008. For more information, visit and follow us on Twitter.

About Phytel
The premier company empowering physician-led population health improvement, Phytel provides physicians with proven technology to deliver timely, coordinated care to their patients. Phytel’s state-of-the-art registry, which now encompasses more than 30 million patients nationwide, uses evidence-based chronic and preventive care protocols to identify and notify patients due for service, while tracking compliance and measuring quality and financial results. Phytel is ISO 9001:2008 certified, confirming adherence to ISO's internationally recognized Total Quality Management (TQM) standards. For more information, please visit Follow us on Twiiter and find us on Facebook.

About Cobalt Talon
A Kansas City, Mo.-based company, Cobalt Talon LLC is a wholly owned subsidiary of Cobalt Ventures LLC – a firm that oversees multiple independent companies offering a wide range of innovative health care-focused services. Cobalt Talon offerings include data management and analytic solutions covering the entire spectrum, from basic reports to advanced analytics. The solutions are designed to help health care organizations face industry-changing events fueled predominantly by recent health care reform law. Cobalt Talon’s portfolio contains advanced analytic modules designed to address specific business unit needs; a fully integrated and hosted enterprise analytic platform developed to handle virtually all of a company's analytic needs; and data management and consulting services, which includes an award-winning health care data model and implementation services. Cobalt Talon’s data enhancement processes and analytic delivery solutions directly enable population health management initiatives, provider efficiency and effectiveness analytics, and the movement to a consumer-based health care market. To learn more about Cobalt Talon or Cobalt Ventures, visit or

Media Contact:
Scott Stuart
P (515) 697-7226
C (515) 4401-2324

The project described was supported by Grant Number CMS-1C1-12-0001 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and have not been approved by the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

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