2014 - PCMH3D

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At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidence-based guidelines.

When choosing preventive care, immunization, and chronic/acute care services to generate lists and reminders for, PCC recommends considering using the same measures you've identified for QI efforts required for element 6A. As explained in the examples below, PCC's Dashboard and recaller tools can be used to identify patients in need of care. PCC's notify program is an integrated tool designed to provide automated reminders to patients in need of services.

3.D.1 At least two different preventive care services.

Description Example/Screenshot/Documentation Source Date Added
Examples of using the recaller and Dashboard for generating lists and reminding patients of preventive care services Preventive care reporting examples PCC 07/07/14

3.D.2 At least two different immunizations.

PCC's Dashboard includes lists of patients overdue for the following immunizations:

  • HPV
  • Meningococcal
  • Tdap

3.D.3 At least three different chronic or acute care services.

Description Example/Screenshot/Documentation Source Date Added
Examples of using the recaller and Dashboard for generating lists and reminding patients of chronic care services Chronic care reporting examples PCC 07/07/14

3.D.4 Patients not recently seen by the practice.

Description Example/Screenshot/Documentation Source Date Added
Examples of using the recaller to identify patients not recently seen by the practice How to identify patients not recently seen PCC 07/07/14

3.D.5 Medication monitoring or alert.

The practice generates lists of patients on specific medications. Lists may be used to:

  • Manage patients prescribed medications with potentially harmful side effects.
  • Identify patients prescribed a brand-name drug instead of a generic drug.
  • Notify patients about a medication recall or warning.
  • Remind patients about necessary monitoring because of specific medications (e.g., warfarin, liver function test for patients on selected medications, growth hormone).
  • Inform patients about drug-drug or dosage concerns.
Description Example/Screenshot/Documentation Source Date Added
Generating lists of patients on medications Generating lists of patients on medications PCC 07/07/14