2014 - PCMH4B: Difference between revisions

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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:
The care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual care plan that includes the following features for at least 75 percent of the patients identified in Element A:


=4.A.1 Behavioral health conditions.  =
=4.B.1 Incorporates patient preferences and functional/lifestyle goals.  =


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=4.A.2 High cost/high utilization.=
=4.B.2 Identifies treatment goals. =


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=4.A.3 Poorly controlled or complex conditions. =
=4.B.3 Assesses and addresses potential barriers to meeting goals. =


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=4.A.4 Social determinants of health.  =
=4.B.4 Includes a self-management plan.  =


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=4.A.5 Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver. =
=4.B.5 Is provided in writing to the 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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Revision as of 01:41, 9 July 2014

Back to PCMH Resources Page

<< Move to previous PCMH element - 4A

>> Move to next PCMH element - 4C

The care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual care plan that includes the following features for at least 75 percent of the patients identified in Element A:

4.B.1 Incorporates patient preferences and functional/lifestyle goals.

Description Example/Screenshot/Documentation Source Date Added

4.B.2 Identifies treatment goals.

Description Example/Screenshot/Documentation Source Date Added

4.B.3 Assesses and addresses potential barriers to meeting goals.

Description Example/Screenshot/Documentation Source Date Added

4.B.4 Includes a self-management plan.

Description Example/Screenshot/Documentation Source Date Added

4.B.5 Is provided in writing to the patient/family/caregiver.

Description Example/Screenshot/Documentation Source Date Added
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