2017 Main

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This wiki serves as an informal repository of PCMH documentation related to the 2017 PCMH Standards released in March 2017. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.

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The 2017 Standards are broken down into six concepts that align with the principles of primary care. Within each concept are competencies which are meant to organize the criteria within each concept area. Criteria are the individual structures, functions and activities that indicate a practice is operating as a medical home.

To achieve recognition under the new PCMH program, practices must:

  • Meet all core criteria
  • Earn 25 credits in elective criteria across 5 of 6 concepts.

This ensures a minimum set of capabilities and gives practices the flexibility to focus on activities that not only mean the most to their patient population, but are feasible to accomplish with regard to their resources and the resources of their community.

Team-Based Care and Practice Organization (TC)

The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.

Competency A (TC01 - TC05) - The practice is committed to transforming the practice into a sustainable medical home

Competency B (TC06 - TC09) - Communication among staff is organized to ensure that patient care is coordinated, safe and effective

Competency C (TC10) - The practice communicates and engages patients on expectations and their role in the medical home model of care

Knowing and Managing Your Patients (KM)

The practice captures and analyzes information about the patients and community it serves and uses the information to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services.

Competency A (KM01 - KM08) - Practice routinely collects comprehensive data on patients to understand background and health risks of patients

Competency B (KM09 - KM11) - The practice seeks to meet the needs of a diverse patient population by understanding the population’s unique characteristics and language needs

Competency C (KM12 - KM13) - The practice proactively addresses the care needs of the patient population to ensure needs are met

Competency D (KM14 - KM19) - The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation and assessment of barriers

Competency E (KM20) - The practice incorporates evidence- based clinical decision support across a variety of conditions to ensure effective and efficient care is provided to patients

Competency F (KM21 - KM28) - The practice identifies/ considers and establishes connections to community resources to collaborate and direct patients to needed support

Patient-Centered Access and Continuity (AC)

The PCMH model expects continuity of care. Patients/families/caregivers have 24/7 access to clinical advice and appropriate care facilitated by their designated clinician/care team and supported by access to their medical record. The practice considers the needs and preferences of the patient population when establishing and updating standards for access.

Competency A (AC01 - AC09) - The practice seeks to enhance access by providing appointments and clinical advice based on patients’ needs

Competency B (AC10 - AC14) - Practices support continuity through empanelment and systematic access to the patient’s medical record

Care Management and Support (CM)

The practice identifies patient needs at the individual and population levels to effectively plan, manage and coordinate patient care in partnership with patients/families/caregivers. Emphasis is placed on supporting patients at highest risk.

Competency A (CM01 - CM03) - The practice systematically identifies patients who may benefit from care management

Competency B (CM04 - CM09) - For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart

Care Coordination and Care Transitions (CC)

The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.

Competency A (CC01 - CC03) - The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result

Competency B (CC04 - CC13) - The practice provides important information in referrals to specialists and tracks referrals until the report is received

Competency C (CC14 - CC21) - The practice connects with health care facilities to support patient safety throughout care transitions

Performance Measurement and Quality Improvement (QI))

The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.

Competency A (QI01 - QI07) - The practice measures to understand current performance and to identify opportunities for improvement

Competency B (QI08 - QI14) - The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies

Competency C (QI15 - QI19) - The practice is accountable for performance. The practice shares performance data with the practice, patients and/or publicly for the measures and patient populations identified in the previous section