Patient-Centered Medical Home (PCMH)

We practice under the Patient-Centered Medical Home (PCMH) model of care. This program is a way of recognizing that you, the patient, are the most important person in the health care system. A medical home is a model of care that focuses on how comprehensive, coordinated, and patient-centered health care services are delivered to individuals and families.

At Albany Area Primary Health Care, Inc. (AAPHC), our health care team serves as the central hub for your medical care. We work closely with you and your provider team to ensure that your health care needs are met through a coordinated and collaborative approach. PCMH places you at the center of your health care experience and provides primary care that is Accessible, Continuous, Comprehensive, Community Oriented, Coordinated, and Compassionate.

AAPHC is committed to helping patients navigate the health care system by coordinating services across providers, specialists, hospitals, diagnostic centers, pharmacies, and community resources when needed. We strive to ensure that patients understand who their primary care provider is, who is rendering their care during each encounter, and how members of the care team work together to support their health goals.

Through coordinated care, our team communicates with providers and other health care partners to support timely follow-up, appropriate referrals, medication management, preventive care services, and continuity of treatment. This approach helps reduce gaps in care, improves communication among health care professionals, and ensures that patients receive the right care at the right time. We encourage patients to actively participate in their health care decisions and partner with us in managing their overall health and wellness.

Our PCMH Responsibilities to You

1. To listen to your questions and concerns and explain diseases, treatments, and test results in an easy-to-understand manner.
2. To coordinate your overall care, including referrals to trusted specialists, hospitals, behavioral health providers, community resources, and other health care services when needed.
3. To work collaboratively with your provider team to ensure continuity of care and timely communication regarding your treatment plan, medications, referrals, and follow-up needs.
4. To help you understand which provider is responsible for your care and ensure you are informed about services being provided during your visit.
5. To provide same-day appointments whenever possible.
6. To provide instructions on how to access the care you need when the office is not open.
7. To provide clear instructions regarding your treatment goals, care plans, preventive screenings, and future health care needs for every visit.
8. To partner with you in managing chronic conditions, preventive care, and wellness goals through ongoing communication and care coordination.

Your Responsibilities in a PCMH

1. To ask questions and be an active participant in your care.
2. To provide your health history and other important information, including any changes in your health, medications, insurance coverage, or contact information.
3. To call our office first with your health concerns unless it is an emergency.
4. To inform us whenever you use another health care service, such as an emergency room, urgent care center, hospital, or specialist, so we can coordinate and document your care.
5. To follow the treatment plans and recommendations discussed with your provider and care team.
6. To keep scheduled appointments and notify the office if you need to cancel or reschedule.
7. To have a clear understanding of your treatment goals and future health goals and communicate any concerns or barriers that may affect your care.
8. To actively participate in care coordination efforts by sharing requested information and working with your care team to achieve the best possible health outcomes.