Process Improvements

  • A multi-physician practice reduced the number of female patients who had not had DEXA scans by more than 20 percent.
  • A multi-physician practice reduced the number of patients with COPD who had not had an annual spirometry test by 31 percent.
  • A small practice raised its rate of screening for depression in the elderly from 11% to 56%, having begun using the PHQ-2 at every visit.
  • A solo physician practice saw a 16 percent improvement in female patients who had needed breast cancer screenings.
  • A solo physician practice improved the rate of pneumococcal vaccinations for patients 65 and older by 11.6 percent.
  • A small physician practice achieved a 6 percent improvement in the rate of tobacco cessation counseling to patients who smoke.


  • A multi-physician practice achieved a 2.6 percent increase, to over 70 percent, in the number of hypertensive patients whose blood pressure was below 140/90.
  • A large multi-site practice reported a 15 percent reduction in hospital admissions for its population in its first year of PCMH implementation, accompanied by an increase in primary care visits and revenue.

Vulnerable Patients

  • A multi-physician practice reduced the number of vulnerable patients needing colonoscopy by 7 percent.
  • A solo physician practice assisted under-insured patients receiving therapy for osteoporosis, ensuring that 100 percent of patients received therapy.
  • The Georgia Academy of Family Physicians would like to congratulate the 2014 PCMH University's 10 practices that graduated in December 2013. All of the graduate practices have either applied for NCQA PCMH recognition or plan to apply within the next six weeks!
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