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Assessment of this element is based on a sample of patients identified in Elements A and B. The sample is drawn from patients seen in the last three months. This sample is also used for the medical record review required in PCMH 3, Elements C and D, and
in PCMH 4, Element A. 

While patients may be identified for care management by diagnosis or condition, the emphasis of the care must be on the whole person over time and on managing all of the patient’s care needs. The practice adopts evidence-based guidelines and uses
them to plan and manage patient care.

The care team performs the following for at least 75 percent of the patients for the patients identified in Elements A and B:

=3.C.1 Conducts pre-visit preparations=

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=3.C.2 Collaborates with the patient/family to develop an individualized care plan, including treatment goals that are reviewed and updated at each relevant visit=

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=3.C.3 Gives the patient/family a written plan of care=

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=3.C.4 Assesses and addresses barriers when patient has not met treatment goals=

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=3.C.5 Provides patient/family a clinical summary at each relevant visit=

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=3.C.6 Identifies patients/families who might benefit from additional care management support=

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=3.C.7 Follows up with patients/families who have not kept important appointments=

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