Hear from a practicing Family Medicine Physician Dr. Holly Cleney on their team approach to care coordination within the community. Learn how their focus on patient centered care across delivery systems has supported effective Care Coordination. Learn from the Lantham Medical Groups practical experience and what their next steps are for their continuous journey of Transformation.Dr. Holly Cleney is a practicing physician with Latham Medical Group in Lathem, New York. She is currently working as a group leader in the Capital District Physicians Health Plan PCMH project centered around transforming a practice into a patient-centered medical home while studying the payment reform model that incorporates risk adjusted capitation as the base payment and rewards for quality and efficiency measures. The program is utilizing Allan Gorroll's Adult Primary Care Comprehensive Payment Model. Dr. Cleney has coordinated the “Team based care” team for the 2 years and enjoyed collaborating with and using ideas from anyone in the office willing to give them to improve our systems of care delivery and encourage every member of the team to understand the content of and importance of their roles as we work to continually define how to improve.