Wikipedia says” The medical home, also known as the patient-centered medical home (PCMH), is a team based health care delivery model led by a physician, P.A., or N.P. that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.”Recently a USNews article http://health.usnews.com * explained how the Cleveland Clinic’s medical home program works.“When Richard Jones of Niles, Ohio, 70, was discharged in May, he was sent home with a digital scale to flag any weight fluctuations (a possible sign of fluid buildup), a blood pressure cuff, and other monitoring equipment tied into the hospital system. He was also assigned a telemonitoring support team of nurses, social workers, nutritionists, therapists, and doctors who would check his vital signs daily, remotely or in person, for up to 40 days. In phone and house calls, the team coordinated follow-up doctor visits and counseled the lifelong cheeseburger-and-fries fan on worrisome symptoms to watch for and how to make lifestyle changes stick.” * to read the full USNews article, “How Healthcare Is Changing—for the Better”, highlight and clck on open hyperlink http://health.usnews.com/health-news/articles/2012/10/18/how-healthcare-is-changingfor-the-better ™