Team-Based and Integrated Care

PCDC enables organizations to integrate services and care teams to drive expert, patient-centered, culturally responsive, and high-quality care.


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We enable health care organizations to create teams and care models that meet the needs of patients and communities. We leverage evidence-based, practical solutions to bring together staff and services across disciplines.

  • 1,100
    practices reached Patient-Centered Medical Home recognition
  • $27M
    achieved in NY incentive payments for practices in 2022
  • 90%
    of training participants demonstrate improvement in knowledge, skills, and confidence 

We help bring it all together

Patients and communities have a multitude of needs stemming from chronic disease, mental health conditions, and substance use disorders, as well as from persistent economic and social barriers. To address these issues, provider organizations must bring care teams together across disciplines, introduce new services, and build new partnerships to meet these needs.

We help providers develop workflows, establish clear roles and responsibilities, and upskill staff to ensure maximum impact for their patients. We also help practices adopt care models  that integrate critical services within practices and across organizations to meet patients’ needs in a single, coordinated setting.

We train. We coach. We consult.

Our staff are experts in addressing common practice challenges through evidence-based quality improvement, including:

  1. Improving access, cycle time, and flow to critical services
  2. Ensuring consistent screening and testing practices, including for HIV/AIDS, behavioral health, and social needs
  3. Achieving National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH), Medicare, and Medicaid reporting and programmatic requirements
  4. Integrating essential services to be responsive to patient and community needs, and
  5. High performance in health plan, state, and federal quality programs
Learn about our training

District of Columbia Primary Care Association

Strengthening coordination and care management services among member Federally Qualified Health Centers (FQHCs) to mitigate patient risk, improve outcomes and reduce avoidable hospitalizations

Ending the Epidemic

Resources to support HIV/AIDS prevention and treatment