Structuring a PCMH Clinic


I am currently a RN/Care Coordinator at a PCMH (Patient Centered Medical Home) clinic that has a unique setup. Though it mostly functions as a family practice clinic we also have a pharmacy, limited function dental clinic and also triage like a urgent care clinic. Because the clinic is geared for the uninsured or underinsured, we get most of our funding from federal funds or grants which means that we have to compile and present a lot of data to prove to funders that we would put their money to good use.

Now, I've been working there for about 5 weeks and have determined that there are some organization issues that need to be ironed out. Not to say that I have a bad work environment or that the clinic is falling apart, I love working there but it sometimes feels like we're shooting from the hip and I think things could run so much smoother. The other two nurses I work with agree with me about this and we are going to start having weekly meetings to hash out a plan to fix things.

I was hoping someone on this site could point me in the direction of some resources to help us accomplish this goal. What we're focused on is:

1. How to spend less time on med refills/referrals/prior authorizations so we can focus more on case management (even though med refills/referrals/prior authorizations tie into case management).

2. How to effectively compile different types of data needed to get grants.

3. How to increase communication and collaboration between the pharmacy, dental clinic, billing, outreach etc.)

Thanks in advance for any advice provided!

I work at a Community Health Center in rural AK. We are working towards PCMH recognition, but not quite there yet. We have structured it so that there is a Clinic RN and a RN Case Manager for each care team. The RN CM and her assistant deal with all the med refills/renewals. The Clinic RN focuses on patient care. Case Management nurses rarely work in the clinic, they process all of our referrals. Sounds like you are responsible for a lot trying to do care coordination and RN clinic work. Good luck :)


2 Articles; 1,406 Posts

Specializes in nursing education.

Look at FQHCs and see if you can visit for a few hours. There are three in my city. Two are chaotic (nobody answers the phone) and one is amazingly welcoming. I cold called one day and was invited for a tour, they love to show off the wonderful work they do. Literally what I did was pick up the phone one day and call them all.

One of the others, I would like to just walk in and see it (I heard they do a "walk in diabetes group" mid-day on Mondays) but I am not free on that day.

I am setting up an afternoon "shadow visit" at one in the next county. I hope to visit in a couple weeks.

Best of luck. PCMH is a great model if done right. It is important to see who else is doing it well- don't reinvent the wheel if you don't have to.