About Us

The Adirondack Medical Home Initiative (AMHI) is

  • building on the foundation of learning from its five-year Patient Centered Medical Home (PCMH) pilot model, and
  • creating actionable steps toward improving quality of care and the patient experience, reducing health care costs and retaining primary care providers (PCP).

Established as a pilot in 2010, this initiative was one of only five Multipayer Advanced Primary Care Practice (MAPCP) programs nationwide eligible for an extension by Centers for Medicare & Medicaid Services (CMS).

Utilizing providers and payer investments to transform systems of care across the entire region, the emphasis is on preventive care, enhanced management of chronic conditions, and assuring a close relationship between patients and their primary care providers.

How AMHI works

We want doctors to concentrate more on quality of care rather than volume of care. The initiative creates funding incentives that reward keeping individuals healthy rather than paying for procedures without regard to effectiveness. Increased contact with a primary care physician can enable earlier diagnosis. Early diagnoses generally translate into better health and lower costs.

For patients, a Medical Home is not a place; rather it’s characterized by increased contact with a primary care practitioner.

  • Patients in the program hear more frequently from their primary care physician.
  • Patients are encouraged to schedule annual exams and stay current with age- and gender-appropriate screenings:
    • pap smears, mammograms, prostate exams, immunizations
  • Patients with chronic conditions can expect:
    • frequent communications from their primary care practice to ensure an effective care plan is being followed;
    • their primary care physician to act as a team leader, coordinating care if a hospitalization or care from a specialist is needed.

The initiative includes primary care practices located in Clinton, Essex, Franklin, and Hamilton counties, an area of nearly 7,000 square miles, and affiliated practices in contiguous counties. There are approximately 100,000 attributed patients in the six North Country counties participating with a medical home practice.

Our participants include:

  • Health care providers in more than 30 participating practices (representing 230 physicians, physician assistants and nurse practitioners);
  • Seven commercial health plans;
  • The New York State Department of Health, the Medical Society of the State of New York, and the New York State Association of Counties.

Our experience with AMHI illustrates how providers and payors working together can contain costs while delivering quality, accessible care that positively impacts individual health in our region.

The AHI Informer

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