2014 - PCMH4E

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The practice has, and demonstrates use of, materials to support patients and families/caregivers in self-management and shared decision making. The practice:

4.E.1 Uses an EHR to identify patient-specific education resources and provide them to more than 10 percent of patients.

PCC EHR has built-in access to two libraries of patient education resources. The AAP’s Pediatric Patient Education library and the NLM’s MedlinePlus library give you instant access to handouts and current medical information on a wide range of topics.

4.E.2 Provides educational materials and resources to patients.

According to NCQA, educational programs and resources may include information about a medical condition or about the patient’s role in managing the condition. Resources include brochures, handout materials, videos, Web site links and pamphlets, as well as community resources (e.g., programs, support groups).

NCQA reviews at least three examples of resources.

4.E.3 Provides self-management tools to record self-care results.

According to NCQA, self-management tools enable patients to collect health information at home that can be discussed with the clinician. Patients with asthma may be asked to monitor peak flows and the self-management plan offers instructions for adjusting medications.

NCQA reviews at least three examples of self-management tools.

4.E.4 Adopts shared decision making aids.

According to NCQA, when a complex decision involves multiple options with features that people may value differently, a shared decision-making aid provides detailed information without advising the audience to choose one decision over another. From time to time, scientific evidence about options is limited. The purpose of SDMs is to help prepare patients to make informed, values-based decisions with their care team. More information and resources can be found through the International Patient Decision Aid Standards Collaboration (IPDASC).

NCQA reviews at least three examples of shared decision making aids.

4.E.5 Offers or refers patients to structured health education programs, such as group classes and peer support.

According to NCQA, the practice would provide (or make available) health education classes, which may include alternative approaches such as peer-led discussion groups or shared medical appointments (i.e., multiple patients meet in a group setting for follow-up or routine care). These types of appointments may offer access to a multidisciplinary care team and allow patients to interact with and learn from each other.

4.E.6 Maintains a current resource list on five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates.

NCQA lists these as possible resource topics or community service areas that may be pertinent to your practice:

  • Smoking cessation.
  • Weight management.
  • Exercise/physical activity.
  • Nutrition.
  • Parenting.
  • Dental.
  • Transportation to medical appointments.
  • Noncommercial health insurance options.
  • Obtaining prescription medications.
  •  Child development.
  • Child care.
  • Breastfeeding.

NCQA will review materials demonstrating that you provide at least 5 resources

4.E.7 Assesses usefulness of identified community resources.

According to NCQA, the practice reviews and requests feedback from patients/families/ caregivers about community referrals, to evaluate whether it identified sufficient and appropriate resources for its population over time. Community referrals differ from clinical referrals, but may be tracked using the same system.

NCQA will review a survey or other materials you've used to assess the usefulness of your identified community resources.