The "medical neighborhood" is defined by the PCPCC as a clinical-community partnership that includes the medical and social supports necessary to enhance health, with the PCMH serving as the patient’s primary “hub” and coordinator of health care delivery. The goals of a high-functioning PCMH include collaborating with these various “medical neighbors” to encourage the flow of information across and between clinicians and patients, to include specialists, hospitals, home health, long term care, and other clinical providers. In addition, non-clinical partners like community centers, faith-based organizations, schools, employers, public health agencies, YMCAs, and even Meals on Wheels. Together these organizations can actively promote care coordination, fitness, healthy behaviors, proper nutrition, as well as healthy environments and workplaces. The Agency for Healthcare Research and Quality (AHRQ) articulates that a successful medical neighborhood will “focus on meeting the needs of the individual patient, but also incorporate aspects of population health and overall community health needs."
