2017 Main - Revision history

Tim at 17:37, 29 May 2018

2018-05-29T17:37:11Z

Tim at 14:49, 6 February 2018

2018-02-06T14:49:04Z

← Older revision		Revision as of 14:49, 6 February 2018
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	===[[2017 - Competency TC-A\|Competency A - The practice is committed to transforming the practice into a sustainable medical home]]===		===[[2017 - Competency TC-A\|Competency A - The practice is committed to transforming the practice into a sustainable medical home]]===

	Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

	===[[2017 - Competency TC-B\|Competency B~~]]===~~		===[[2017 - Competency TC-B\|Competency B - Communication among staff is organized to ensure that patient care is coordinated, safe and effective]]===
	Communication among staff is organized to ensure that patient care is coordinated, safe and effective.

	===[[2017 - Competency TC-C\|Competency C~~]]===~~		===[[2017 - Competency TC-C\|Competency C - The practice communicates and engages patients on expectations and their role in the medical home model of care]]===
	The practice communicates and engages patients on expectations and their role in the medical home model of care.

	==Knowing and Managing Your Patients (KM)==		==Knowing and Managing Your Patients (KM)==
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	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.		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.

	===[[2017 - Competency KM-A\|Competency A~~]]===~~		===[[2017 - Competency KM-A\|Competency A - Practice routinely collects comprehensive data on patients to understand background and health risks of patients]]===
	Practice routinely collects comprehensive data on patients to understand background and health risks of patients~~. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.~~

	===[[2017 - Competency KM-B\|Competency B~~]]===~~		===[[2017 - Competency KM-B\|Competency B - The practice seeks to meet the needs of a diverse patient population by understanding the population’s unique characteristics and language needs]]===
	The practice seeks to meet the needs of a diverse patient population by understanding the population’s unique characteristics and language needs~~. The practice uses this information to ensure linguistic and other patient needs are met.~~

	===[[2017 - Competency KM-C\|Competency C~~]]===~~		===[[2017 - Competency KM-C\|Competency C - The practice proactively addresses the care needs of the patient population to ensure needs are met]]===
	The practice proactively addresses the care needs of the patient population to ensure needs are met.

	===[[2017 - Competency KM-D\|Competency D~~]]===~~		===[[2017 - Competency KM-D\|Competency D - The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation and assessment of barriers]]===
	The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation and assessment of barriers.

	===[[2017 - Competency KM-E\|Competency E~~]]===~~		===[[2017 - Competency KM-E\|Competency E - The practice incorporates evidence- based clinical decision support across a variety of conditions to ensure effective and efficient care is provided to patients]]===
	The practice incorporates evidence- based clinical decision support across a variety of conditions to ensure effective and efficient care is provided to patients.

	===[[2017 - Competency KM-F\|Competency F~~]]===~~		===[[2017 - Competency KM-F\|Competency F - The practice identifies/ considers and establishes connections to community resources to collaborate and direct patients to needed support]]===
	The practice identifies/ considers and establishes connections to community resources to collaborate and direct patients to needed support.

	==Patient-Centered Access and Continuity (AC)==		==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.		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.

	===[[2017 - Competency AC-A\|Competency A~~]]===~~		===[[2017 - Competency AC-A\|Competency A - The practice seeks to enhance access by providing appointments and clinical advice based on patients’ needs]]===
	The practice seeks to enhance access by providing appointments and clinical advice based on patients’ needs.

	===[[2017 - Competency AC-B\|Competency B~~]]===~~		===[[2017 - Competency AC-B\|Competency B - Practices support continuity through empanelment and systematic access to the patient’s medical record]]===
	Practices support continuity through empanelment and systematic access to the patient’s medical record.

	==Care Management and Support (CM)==		==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.		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.

	===[[2017 - Competency CM-A\|Competency A~~]]===~~		===[[2017 - Competency CM-A\|Competency A - The practice systematically identifies patients who may benefit from care management]]===
	The practice systematically identifies patients who may benefit from care management.

	===[[2017 - Competency CM-B\|Competency B~~]]===~~		===[[2017 - Competency CM-B\|Competency B - 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]]===
	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)==		==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.		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.

	===[[2017 - Competency CC-A\|Competency A~~]]===~~		===[[2017 - Competency CC-A\|Competency A - The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result]]===
	The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result.

	===[[2017 - Competency CC-B\|Competency B~~]]===~~		===[[2017 - Competency CC-B\|Competency B - The practice provides important information in referrals to specialists and tracks referrals until the report is received]]===
	The practice provides important information in referrals to specialists and tracks referrals until the report is received.

	===[[2017 - Competency CC-C\|Competency C~~]]===~~		===[[2017 - Competency CC-C\|Competency C - The practice connects with health care facilities to support patient safety throughout care transitions]]===
	The practice connects with health care facilities to support patient safety throughout care transitions~~. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.~~

	==Performance Measurement and Quality Improvement (QI))==		==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.		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.

	===[[2017 - Competency QI-A\|Competency A~~]]===~~		===[[2017 - Competency QI-A\|Competency A - The practice measures to understand current performance and to identify opportunities for improvement]]===
	The practice measures to understand current performance and to identify opportunities for improvement.

	===[[2017 - Competency QI-B\|Competency B~~]]===~~		===[[2017 - Competency QI-B\|Competency B - The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies]]===
	The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies.

	===[[2017 - Competency QI-C\|Competency C~~]]===~~		===[[2017 - Competency QI-C\|Competency C - 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]]===
	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.

Tim at 14:40, 6 February 2018

2018-02-06T14:40:35Z

← Older revision		Revision as of 14:40, 6 February 2018
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	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.		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.

	===[[2017 - Competency TC-A\|Competency A~~]]===~~ The practice is committed to transforming the practice into a sustainable medical home~~. Members of the care team serve specific roles as defined by the practice’s organizational structure and are equipped with the knowledge and training necessary to perform those functions~~		===[[2017 - Competency TC-A\|Competency A - The practice is committed to transforming the practice into a sustainable medical home]]===

	Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.		Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

Tim at 14:38, 6 February 2018

2018-02-06T14:38:40Z

← Older revision		Revision as of 14:38, 6 February 2018
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	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.		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.

	===[[2017 - Competency TC-A\|Competency A]]===		===[[2017 - Competency TC-A\|Competency A]]=== The practice is committed to transforming the practice into a sustainable medical home. Members of the care team serve specific roles as defined by the practice’s organizational structure and are equipped with the knowledge and training necessary to perform those functions

	Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.		Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

Tim at 16:45, 10 August 2017

2017-08-10T16:45:23Z

Show changes

Tim: /* Team-Based Care and Practice Organization (TC) */

2017-08-10T16:29:03Z

Team-Based Care and Practice Organization (TC)

← Older revision		Revision as of 16:29, 10 August 2017
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	Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.		Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

	===[[2017 - Competency B\|Competency B===		===[[2017 - Competency B\|Competency B]]===
	Communication among staff is organized to ensure that patient care is coordinated, safe and effective.		Communication among staff is organized to ensure that patient care is coordinated, safe and effective.

	===[[2017 - Competency C\|Competency C===		===[[2017 - Competency C\|Competency C]]===
	The practice communicates and engages patients on expectations and their role in the medical home model of care.		The practice communicates and engages patients on expectations and their role in the medical home model of care.

Tim: /* Team-Based Care and Practice Organization (TC) */

2017-08-10T16:28:49Z

Team-Based Care and Practice Organization (TC)

← Older revision		Revision as of 16:28, 10 August 2017
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	Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.		Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

	===[[~~2014~~ - ~~PCMH1B~~\|~~PCMH1B - 24/7 Access to Clinical Advice (3.5 points)]]~~===		===[[2017 - Competency B\|Competency B===
	===[[~~2014~~ - ~~PCMH1C~~\|~~PCMH1C - Electronic Access (2 points)]]~~===		Communication among staff is organized to ensure that patient care is coordinated, safe and effective.

			===[[2017 - Competency C\|Competency C===
			The practice communicates and engages patients on expectations and their role in the medical home model of care.

	==PCMH 2: Team-Based Care (12 points)==		==PCMH 2: Team-Based Care (12 points)==

Tim at 16:25, 10 August 2017

2017-08-10T16:25:19Z

← Older revision		Revision as of 16:25, 10 August 2017
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	The intent of this concept is:		The intent of this concept is:

	===[[2017 - Competency A]]===		===[[2017 - Competency A\|Competency A]]===
	Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.		Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

Tim at 16:24, 10 August 2017

2017-08-10T16:24:49Z

← Older revision		Revision as of 16:24, 10 August 2017
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	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.		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.

	==~~PCMH 1: Patient~~-~~Centered Access~~ (~~10 points~~)==		==Team-Based Care and Practice Organization (TC)==

	The intent of this ~~standard~~ is:		The intent of this concept is:

			===[[2017 - Competency A]]===
			Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

	~~===[[2014 - PCMH1A\|PCMH1A - Patient-Centered Appointment Access (4.5 points) ('''Must Pass''')]]===~~
	===[[2014 - PCMH1B\|PCMH1B - 24/7 Access to Clinical Advice (3.5 points)]]===		===[[2014 - PCMH1B\|PCMH1B - 24/7 Access to Clinical Advice (3.5 points)]]===
	===[[2014 - PCMH1C\|PCMH1C - Electronic Access (2 points)]]===		===[[2014 - PCMH1C\|PCMH1C - Electronic Access (2 points)]]===

Tim: Created page with "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 wh..."

2017-08-10T16:07:57Z

Created page with "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 wh..."

New page

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.

{| style="float: right; border:2px solid #616F7C;background-color:whitesmoke;padding:2px;width:30%;margin: 0 auto 1em auto;"
|-
| Most Recently Updated Elements
|-
|<news limit="10" nominor unique>
* [[{{{pagename}}}]] ({{{timeanddate}}})
</news>
|-
|}

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.

==PCMH 1: Patient-Centered Access (10 points)==

The intent of this standard is:

===[[2014 - PCMH1A|PCMH1A - Patient-Centered Appointment Access (4.5 points) ('''Must Pass''')]]===
===[[2014 - PCMH1B|PCMH1B - 24/7 Access to Clinical Advice (3.5 points)]]===
===[[2014 - PCMH1C|PCMH1C - Electronic Access (2 points)]]===

==PCMH 2: Team-Based Care (12 points)==

The intent of this standard is:

===[[2014 - PCMH2A|PCMH2A - Continuity (3 points)]]===
===[[2014 - PCMH2B|PCMH2B - Medical Home Responsibilities (2.5 points)]]===
===[[2014 - PCMH2C|PCMH2C - Culturally and Linguistically Appropriate Services (2.5 points)]]===
===[[2014 - PCMH2D|PCMH2D - The Practice Team ('''Must Pass''') (4 points)]]===

==PCMH 3: Population Health Management (20 points)==

The practice uses a comprehensive health assessment and evidence-based decision support based on complete patient information and clinical data to manage the health of its entire patient population.

===[[2014 - PCMH3A|PMCH3A - Patient Information (3 points)]]===
===[[2014 - PCMH3B|PMCH3B - Clinical Data (4 points)]]===
===[[2014 - PCMH3C|PMCH3C - Comprehensive Health Assessment (4 points)]]===
===[[2014 - PCMH3D|PMCH3D - Use Data for Population Management ('''Must Pass''') (5 points)]]===
===[[2014 - PCMH3E|PMCH3E - Implement Evidence-Based Decision Support (4 points)]]===

==PCMH 4: Care Management and Support (20 points)==

Intent of Standard: The practice systematically identifies individual patients and plans, manages and coordinates care, based on need.

===[[2014 - PCMH4A|PMCH4A - Identify Patients for Care Management (4 points)]]===
===[[2014 - PCMH4B|PMCH4B - Care Planning and Self-Care Support (4 points) ('''Must Pass''')]]===
===[[2014 - PCMH4C|PMCH4C - Medication Management (4 points) ]]===
===[[2014 - PCMH4D|PMCH4D - Use Electronic Prescribing (3 points) ]]===
===[[2014 - PCMH4E|PMCH4E - Support Self-Care and Shared Decision Making (5 points) ]]===

==PCMH 5: Care Coordination and Care Transitions (18 points)==

The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations.

===[[2014 - PCMH5A|PMCH5A - Test Tracking and Follow-Up (6 points)]]===
===[[2014 - PCMH5B|PMCH5B - Referral Tracking and Follow-Up ('''Must Pass''') (6 points)]]===
===[[2014 - PCMH5C|PMCH5C - Coordinate Care Transitions (6 points)]]===

==PCMH 6: Performance Measurement and Quality Improvement (20 points)==

The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.

===[[2014 - PCMH6A|PMCH6A - Measure Clinical Quality Performance (3 points)]]===
===[[2014 - PCMH6B|PMCH6B - Measure Resource Use and Care Coordination (3 points)]]===
===[[2014 - PCMH6C|PMCH6C - Measure Patient/Family Experience (4 points)]]===
===[[2014 - PCMH6D|PMCH6D - Implement Continuous Quality Improvement ('''Must Pass''') (4 points)]]===
===[[2014 - PCMH6E|PMCH6E - Demonstrate Continuous Quality Improvement (3 points)]]===
===[[2014 - PCMH6F|PMCH6F - Report Performance (3 points)]]===
===[[2014 - PCMH6G|PMCH6G - Use Certified EHR Technology (0 points)]]===

← Older revision		Revision as of 17:37, 29 May 2018
Line 24:		Line 24:
	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.		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.

	===[[2017 - Competency TC-A\|Competency A - The practice is committed to transforming the practice into a sustainable medical home]]===		===[[2017 - Competency TC-A\|Competency A (TC01 - TC05) - The practice is committed to transforming the practice into a sustainable medical home]]===

	===[[2017 - Competency TC-B\|Competency B - Communication among staff is organized to ensure that patient care is coordinated, safe and effective]]===		===[[2017 - Competency TC-B\|Competency B (TC06 - TC09) - Communication among staff is organized to ensure that patient care is coordinated, safe and effective]]===

	===[[2017 - Competency TC-C\|Competency C - The practice communicates and engages patients on expectations and their role in the medical home model of care]]===		===[[2017 - Competency TC-C\|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)==		==Knowing and Managing Your Patients (KM)==
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	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.		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.

	===[[2017 - Competency KM-A\|Competency A - Practice routinely collects comprehensive data on patients to understand background and health risks of patients]]===		===[[2017 - Competency KM-A\|Competency A (KM01 - KM08) - Practice routinely collects comprehensive data on patients to understand background and health risks of patients]]===

	===[[2017 - Competency KM-B\|Competency B - The practice seeks to meet the needs of a diverse patient population by understanding the population’s unique characteristics and language needs]]===		===[[2017 - Competency KM-B\|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]]===

	===[[2017 - Competency KM-C\|Competency C - The practice proactively addresses the care needs of the patient population to ensure needs are met]]===		===[[2017 - Competency KM-C\|Competency C (KM12 - KM13) - The practice proactively addresses the care needs of the patient population to ensure needs are met]]===

	===[[2017 - Competency KM-D\|Competency D - The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation and assessment of barriers]]===		===[[2017 - Competency KM-D\|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]]===

	===[[2017 - Competency KM-E\|Competency E - The practice incorporates evidence- based clinical decision support across a variety of conditions to ensure effective and efficient care is provided to patients]]===		===[[2017 - Competency KM-E\|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]]===

	===[[2017 - Competency KM-F\|Competency F - The practice identifies/ considers and establishes connections to community resources to collaborate and direct patients to needed support]]===		===[[2017 - Competency KM-F\|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)==		==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.		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.

	===[[2017 - Competency AC-A\|Competency A - The practice seeks to enhance access by providing appointments and clinical advice based on patients’ needs]]===		===[[2017 - Competency AC-A\|Competency A (AC01 - AC09) - The practice seeks to enhance access by providing appointments and clinical advice based on patients’ needs]]===

	===[[2017 - Competency AC-B\|Competency B - Practices support continuity through empanelment and systematic access to the patient’s medical record]]===		===[[2017 - Competency AC-B\|Competency B (AC10 - AC14) - Practices support continuity through empanelment and systematic access to the patient’s medical record]]===

	==Care Management and Support (CM)==		==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.		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.

	===[[2017 - Competency CM-A\|Competency A - The practice systematically identifies patients who may benefit from care management]]===		===[[2017 - Competency CM-A\|Competency A (CM01 - CM03) - The practice systematically identifies patients who may benefit from care management]]===

	===[[2017 - Competency CM-B\|Competency B - 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]]===		===[[2017 - Competency CM-B\|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)==		==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.		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.

	===[[2017 - Competency CC-A\|Competency A - The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result]]===		===[[2017 - Competency CC-A\|Competency A (CC01 - CC03) - The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result]]===

	===[[2017 - Competency CC-B\|Competency B - The practice provides important information in referrals to specialists and tracks referrals until the report is received]]===		===[[2017 - Competency CC-B\|Competency B (CC04 - CC13) - The practice provides important information in referrals to specialists and tracks referrals until the report is received]]===

	===[[2017 - Competency CC-C\|Competency C - The practice connects with health care facilities to support patient safety throughout care transitions]]===		===[[2017 - Competency CC-C\|Competency C (CC14 - CC21) - The practice connects with health care facilities to support patient safety throughout care transitions]]===

	==Performance Measurement and Quality Improvement (QI))==		==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.		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.

	===[[2017 - Competency QI-A\|Competency A - The practice measures to understand current performance and to identify opportunities for improvement]]===		===[[2017 - Competency QI-A\|Competency A (QI01 - QI07) - The practice measures to understand current performance and to identify opportunities for improvement]]===

	===[[2017 - Competency QI-B\|Competency B - The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies]]===		===[[2017 - Competency QI-B\|Competency B (QI08 - QI14) - The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies]]===

	===[[2017 - Competency QI-C\|Competency C - 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]]===		===[[2017 - Competency QI-C\|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]]===