PCC PCMH Resources

This wiki serves as an informal repository of PCMH documentation. Much 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.

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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.