Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms


Key Questions: What are the gaps in the healthcare system? How can we better work together? 

Medical neighbourhoods are a diverse array of clinicians and institutions, currently with little to no coordination between them, leaving patients and their families to navigate the fragmented system. A Patient-Centered Medical Home (PCMH) aims to eliminate the non-coherent elements of the healthcare system by shifting the orientation towards coordinated care. Improved communication and cooperation between and across health care providers and institutions are keys to achieving better patient care experience, improved quality of care, and reduced costs. This paper examines the various “neighbors” in the medical neighborhood and how these neighbors could work together better, thus allowing the PCMH to reach its full potential to improve patient outcomes. Specifically, the paper addresses (1) key components of the medical neighborhood and how the PCMH is situated within it; (2) existing barriers to achieving a well-functioning medical neighborhood; and (3) the approaches and tools available to achieve a well-functioning neighborhood, and the strengths and weaknesses of each.


  • Chapter 1 Introduction and Background
  • Chapter 2. Defining the Medical Neighborhood Concept
  • Chapter 3. Making the Medical Neighborhood Work: Barriers and Potential
  • Chapter 4. Conclusions and Future Research
  • References
  • Appendix
  • Tables
  • Figures
Contact Person/Organization: 

AHRQMathematica Policy Research

Type of Tool:

Publication Date: 

Making a Medical Neighborhood Happen

Population Health Management in the Medical Neighborhood