PCC PCMH Resources

What is this page all about? Why did we create it? Who is it for?

PCMH 1: Enhance Access and Continuity (20 points)

The intent of this standard is:

• Patients have access to routine/urgent care and clinical advice during/after hours that is culturally and linguistically appropriate.
• Patients have electronic access
• Clinician selected by patient
• Team based Care - trained staff

PCMH 2: Identify and Manage Patient Populations (16 points)

The intent of this standard is:

• Electronic systems have searchable fields for demographic and clinical data
• Patients receive documented comprehensive health assessments
• Electronic systems used to identify patients who need services

PCMH 3: Plan and Manage Care (17 points)

The practice systematically identifies individual patients and plans, manages and coordinates their care based on their condition and needs and on evidence-based guidelines.

PCMH 4: Provide Self-Care Support and Community Resources (9 points)

Intent of Standard: The practice acts to improve patients' ability to manage their health by providing a selfcare plan, tools, educational resources and ongoing support.

PCMH 5: Track and Coordinate Care (18 points)

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

PCMH 6: Measure and Improve Performance (20 points)

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