Coordinating Care in the Medical Neighborhood

Critical Components & Available Mechanisms

"A medical neighborhood is defined as a medical home and the constellation of other clinicians providing health care services to patients within it, along with community and social service organizations."


For most patients in the U.S. health care system, the “medical neighborhood” appears as a diverse array of clinicians and institutions with little or no coordination between them, leaving patients and their families to navigate this system on their own and often to serve as the main conduit of information between the clinicians they see. Most patients and their families have little understanding of how their primary care practice coordinates (if at all) with other clinicians, organizations, and institutions in the neighborhood— and often may assume that the system is much more coherent, organized, and coordinated than it is. One approach to decreasing fragmentation, improving coordination, and placing greater emphasis on the needs of patients is the patient-centered medical home (PCMH). Its components include patient-centered care with an orientation toward the whole person, comprehensive care, care coordinated across all the elements of the health system, superb access to care, and a systems-based approach to quality and safety. Ultimately, these components are intended to improve patient outcomes—including better patient experience with care, improved quality of care (leading to better health), and reduced costs. 

Many of the goals of the PCMH rely on improved communication and coordination between and across health care providers and institutions: in other words, they require a high-functioning medical neighborhood that (1) encourages the flow of information across and between clinicians and patients, and (2) introduces some level of accountability to ensure that clinicians readily participate in that information exchange. Given that its locus is squarely within the primary care settings of the health system, and the fact that many patients require a substantial amount of specialty care, the PCMH alone can do only so much in creating and promoting the functioning of the medical neighborhood. Thus, specialists, hospitals, other providers, health plans, and other stakeholders also play key roles in ensuring a close-knit neighborhood. At its core, a well-functioning medical neighborhood requires basic communication and coordination

  1. Specialists need to let primary care clinicians know what type of routine care the patient needs after a surgery or course of treatment.
  2. Primary care clinicians need to make appropriate referrals and provide specialists with appropriate background information, clinical data on the patient, and goals for the consultation.
  3. Hospitals need to let primary care teams know when their patients are in the hospital or have visited the hospital’s emergency department (ED).
  4. In general, primary care clinicians and other team members need a broad understanding of each patient’s health care needs to assist in coordinating all care, help the patient navigate the system, and ensure that the treatment plans (and prescription medications) of different specialists work together as a whole.


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