PCMH3A

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>> Move to next PCMH element - 3B

The practice maintains continuous relationships with patients through care management processes based on evidence-based guidelines. A key to successful implementation of guidelines is to embed them in the practice’s day-to-day operations and by using registries that proactively identify and engage patients who are lacking important services (as in PCMH 2, Element D).

The practice implements evidence-based guidelines through point of care reminders for patients with 3 important conditions.

When selecting conditions, you should consider the following:

  • Diagnoses and risk factors prevalent in patients seen by the practice (data from PCMH 2, Elements B and C)
  • Pick conditions where care management, medication management, and self-management support play a role in reducing complications
  • Pick conditions for which there are evidence-based clinical guidelines
  • Patients with the conditions selected in factors 1–3 will be used for the medical record review required in Elements 3.C and 3.D, and in PCMH 4, Element A.

3.A.1 The first important condition

Description Example/Screenshot/Documentation Source Date Added
Example of using well child care as an important condition in PCC EHR Using Well Child Care as an important condition PCC 07/07/14
Chart samples, handouts, etc. Asthma Example TPC 03/25/13
Additional examples Additional examples TPC 03/25/13

3.A.2 The second important condition

Description Example/Screenshot/Documentation Source Date Added
Example of using prematurity as an important condition in PCC EHR Using prematurity as an important condition PCC 07/07/14
Chart samples, handouts, etc. Well Child Example TPC 03/25/13
Additional examples Additional examples TPC 03/25/13

3.A.3 The third condition, related to unhealthy behaviors or mental health or substance abuse (critical factor)

At least one identified condition must be related to unhealthy behaviors (e.g., obesity, smoking), substance abuse (e.g., drug addiction, alcoholism) or a mental health issue (e.g., depression, anxiety, ADHD).

Description Example/Screenshot/Documentation Source Date Added
Example of using ADHD as an important condition in PCC EHR Using ADHD as an important condition PCC 07/07/14
Chart samples, handouts, etc. ADHD Example TPC 03/25/13
Additional examples Additional examples TPC 03/25/13