PCMH3A

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The practice maintains continuous relationships with patients through care management processes based on evidence-based guidelines. A key to successful implementation of guidelines is to embed them in the practice’s day-to-day operations and by using registries that proactively identify and engage patients who are lacking important services (as in PCMH 2, Element D).

The practice implements evidence-based guidelines through point of care reminders for patients with:

3.A.1 The first important condition

When selecting conditions, you should consider the following:

• Diagnoses and risk factors prevalent in patients seen by the practice (data from PCMH 2, Elements B and C)
• Pick conditions where care management, medication management, and self-management support play a role in reducing complications
• Pick conditions for which there are evidence-based clinical guidelines
• Patients with the conditions selected in factors 1–3 will be used for the medical record review required in Elements C and D, and in PCMH 4, Element A.

3.A.3 The third condition, related to unhealthy behaviors or mental health or substance abuse (critical factor)

At least one identified condition must be related to unhealthy behaviors (e.g., obesity, smoking), substance abuse (e.g., drug addiction, alcoholism) or a mental health issue (e.g., depression, anxiety, ADHD).