2014 - PCMH2D

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Move to next PCMH element - 3A

The practice uses a team to provide a range of patient care services by:

2.D.1 Defining roles for clinical and nonclinical team members.

2.D.2 Identifying the team structure and the staff who lead and sustain team based care.

2.D.3 Holding scheduled patient care team meetings or a structured communication process focused on individual patient care. (CRITICAL FACTOR)

Team meetings may be informal daily meetings or review daily schedules, with follow-up tasks. A structured communication process may include regular e-mail exchanges, tasks or messages about a patient in the medical record and how the clinician or team leader is engaged in the communication structure.

2.D.4 Using standing orders for services.

Standing orders should be documented and examples provided.

Description Example/Screenshot/Documentation Source Date Added
Document describing how PCC EHR uses standing orders Using standing orders in PCC EHR PCC 07/03/14

2.D.5 Training and assigning members of the care team to coordinate care for individual patients.

2.D.6 Training and assigning members of the care team to support patients/families/caregivers in self-management, self-efficacy and behavior change.

2.D.7 Training and assigning members of the care team to manage the patient population.

2.D.8 Holding scheduled team meetings to address practice functioning.

2.D.9 Involving care team staff in the practice’s performance evaluation and quality improvement activities.

Measures chosen to meet clinical quality improvement objectives outlined in element 6A should have results shared regularly with care team staff who should be directly involved with the practice QI activities.

2.D.10 Involving patients/families/caregivers in quality improvement activities or on the practice’s advisory council.