PCMH3C

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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.

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. For documentation for this element, you would use the NCQA's Record Review Workbook identifying whether each task was performed for the chosen sample of patients.

3.C.1 Conducts pre-visit preparations

Example: The practice asks patients (e.g., by letter or e-mail) to complete required paperwork before a scheduled visit, in addition to lab tests, imaging tests or referral visits. The practice reviews test results before the visit. This process can be part of the team daily huddle or a protocol, procedure or checklist.

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

Example: Individualized care plans developed in collaboration with the patient/family address the patient’s care needs, the responsibilities of the medical home and of specialists to whom the patient is referred and the role of community services and support, if appropriate. Care plans must include treatment goals and may be based on a template.

At each relevant visit, the clinician uses indicators from evidence-based practice guidelines, such as lab test results, patient symptoms (e.g., depression symptoms), blood pressure or asthma functional score, to determine patient progress with the care plan and treatment goals, or documents deviation from established guidelines and includes the rationale.

Relevant visits are determined by the practice and the clinician, but should be with regard to:

• Important or chronic conditions, including well-child visits for practices with pediatric patients
• Visits that result in a change in treatment plan or goals
• Additional instructions or information for the patient/family
• Visits associated with transitions of care.

If you use well child visits as an important condition, you may use development markers specified by the American Academy of Pediatrics (eg, Bright Futures) to assess progress.

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

The practice gives the patient and/or family a care plan tailored for the patient’s home use and to the patient’s understanding. Well visit anticipatory guidance could be used if you have identified well visits as an important condition in 3A

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

The clinician or care team assesses or talks with the patient/family to determine reasons for limited progress toward treatment goals, and to help the patient/family address barriers (e.g., patient’s lack of understanding or motivation, financial need, insurance issues, adverse effects of medication or other treatment or transportation problems). The clinician or care team changes the treatment plan or adds treatment, if appropriate. A completed social history is acceptable as documentation that the clinician or care team has assessed the patient’s progress.

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

Relevant visits are determined by the practice and the clinician but be with regard to:

• Important or chronic conditions, including well-child care visits for practices with pediatric patients
• Visits that result in a change in treatment plan or goals
• Additional instructions or information for the patient or family.

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

When appropriate, you refer patients to other resources (external or internal) for additional care management support

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

You should be able to get credit for this if you describe your process for tracking patients with these conditions and how you would identify if they have not kept important appointments.

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