WellSpan Health, a community-owned not-for-profit health system and a leader in population health management, knows what it takes to align health care services with the Patient Centered Medical Home (PCMH). WellSpan's leadership has committed to a complete re-design of care team roles, not just in primary care, but throughout the hospital, specialty practices and community-based services. Their innovative model builds on the trusted relationship between patients and their primary care team to ensure high-quality, coordinated care, based on the needs of the patient and family. WellSpan shared the story of their transformation work across the community and described key strategies which include implementing decision making tools, data transparency, team meetings, patient partners and performance improvement efforts.