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Patients experience lots of bumps in the road throughout the healthcare system, poor quality and high cost care resulting in poor outcomes. Our PCMH delivers the care our patients need in the setting they prefer, for best health outcomes. Healthier patients are seen at the practice or connect with us via the patient portal to manage conditions like hypertension with increasing reliance on self-monitoring. One patient was intercepted on his way to the ER for a 2nd time in 2 days and seen at our practice right away. A team from our practice (the nurse practitioner-care manager coupled with a medical assistant) conducts home visits on patients with mobility issues or who have social issues affecting health outcomes. The doctor will make rounds at hospitals during more complex admissions. With a hospice nearby, the doctor visits patients at the end of life. Our PCMH centers on the Triple Aim, smoothing the road for patients who deserve the best care at a cost affordable to all.