2014 - PCMH4A

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The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of the following:

4.A.1 Behavioral health conditions.

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4.A.2 High cost/high utilization.

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4.A.3 Poorly controlled or complex conditions.

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4.A.4 Social determinants of health.

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4.A.5 Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver.

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4.A.6. The practice monitors the percentage of the total patient population identified through its process and criteria. CRITICAL FACTOR)

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