The Role of the Dietitian in the Patient-Centered Medical Home

March 2nd, 2021

By Christina LiPuma, RDN, LDN

One of the things that initially attracted me to the practice of dietetics was the myriad of settings in which a dietitian can work and truly make an impact. As I progressed through my internship, one setting really blew me away–the patient-centered medical home (PCMH). After a one-week rotation, I was hooked. For the last three years now, I have been working as the dietitian in a PCMH in Philadelphia. Here I share my experience as a PCMH dietitian and highlight how this form of integrated care is both excellent for patients and full of opportunities for RDN’s!  

What is a PCMH?

 The PCMH is a primary care setting featuring a patient-centered model that focuses on improving access to the primary care team by reducing barriers for the patients. For example, the PCMH I work at has primary care, OB/GYN, podiatry, behavioral health, case management, dental services, a pharmacy, and nutrition all in one building. The ability to see multiple providers on the same day reduces the amount of time patients have to miss from work, school, or daily life and reduces no-show rates. Additionally, our patients can get same-day appointments when needed, access their providers through a patient portal or on-call service, and the clinic is located right in their neighborhood to reduce travel burden.  

The PCMH works to build relationships with both the patients and the community in which it operates. My clinic does this by hosting classes, health fairs, and other events for the whole community (not just our patients). We partner with the farmer’s market and do free food giveaways when possible. These things together facilitate better relationships with patients and more actively engages them in care.

Does the PCMH actually work?

A growing body of research demonstrates that health clinics with the PCMH designation bring down healthcare costs and improve patient outcomes. Studies have shown that cost savings arise from decreased usage of ER/hospitalizations, increased use of health screenings, and improved monitoring/outreach of high-risk chronic care patients.  In diabetes patients specifically, studies have shown that PCMH’s produce significant increases in control of A1C, blood pressure, and LDL cholesterol.

How do dietitians fit in?

The dietitian in the PCMH wears many hats. Day to day, my roles typically include counseling, care coordination, community nutrition, improving food access for patients, and clinic staff education.  


Similar to an outpatient counseling job, the bulk of time for a PCMH dietitian is spent in one-on-one counseling with patients. One of my favorite things about being a PCMH dietitian is the unique opportunity to work with low-income patients. Unfortunately, current insurance coverage for Medicaid plans is very poor; however, in the PCMH setting, the RDN is still supported by funding that comes from government grants designed specifically to improve access to care for low-income patients. This allows the dietitian to provide MNT for patients with a wide variety of diagnoses and needs, regardless of their ability to pay.

Care Coordination

Every staff member of the PCMH is involved to some extent in care coordination, such as connecting patients to any resources they need and ensuring all team members are on the same page with the patient’s care. This can mean scheduling a patient with a specialist or talking face to face with the behavioral health specialist or social worker to ensure all the patient’s health barriers are addressed. Pre-COVID, we even did warm handoffs to other services, which meant I could literally walk a patient who was struggling down the hall to speak with someone the same day about their pressing mental health or resource needs.  

Community Nutrition

 PCMH dietitians are also regularly involved in educating both the patients and the community in which the patients live. For me, this has taken the form of running a monthly plant-based nutrition cooking class and a diabetes support group. However, community nutrition for a PCMH dietitian can also involve presentations at health fairs, senior centers, and programming at other local organizations.

Improving Food Access

Because many PCMH’s have patients who struggle with food insecurity, the PCMH dietitian often serves as the connection between patients and crucial food resources. I spend significant amounts of time familiarizing myself with food access resources in the neighborhood to connect my patients when this barrier arises. This includes food pantries, senior centers, congregate meal sites, and meal delivery programs like Meals on Wheels. I also collaborate with the farmer’s market to make it possible for them to maintain a weekly site in our clinic’s neighborhood.

Staff Education

Finally, the PCMH dietitian serves as an educator of the other staff members in the clinic. This is a role I was not expecting, but from doctors to behavioral health specialists to medical assistants, I was surprised how many of my coworkers had questions about nutrition. Since everyone interacts with our patients directly, I find it helpful to provide ongoing education for the staff to keep our nutrition message unified.  


I won’t pretend the PCMH is a workplace without some challenges, but even through the pandemic and the shift to telehealth I have continued to enjoy the teamwork, respect, and fulfillment that working in integrated care fosters. This unique setting allows dietitians to collaborate seamlessly with all members of the patient’s care team, serve the community, fight food insecurity, and work with patients who might not otherwise be able to afford MNT. For me, this has translated to immense job satisfaction and pride in the work that I do!


  1. Bojadzievski, Trajko, and Robert A Gabbay. “Patient-Centered Medical Home and Diabetes.” Diabetes Care, vol. 34, no. 4, Apr. 2011, pp. 1047–1053., doi:
  2. 2021. Benefits of NCQA Patient-Centered Medical Home Recognition. [online] Available at: <> [Accessed 19 February 2021].


Christina LiPuma is a registered dietitian currently working for Spectrum Health Services, a Federally Qualified Health Center with Patient-Centered Medical Home status in West Philadelphia.  


Posted by: Talia Follador

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