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
PCMH1A - Access During Office Hours (4 points) (Must Pass)
PCMH1B - After-hours access (4 points)
PCMH1C - Electronic Access (2 points)
PCMH1D - Continuity (2 points)
PCMH1E - Medical Home Responsibilities (2 points)
PCMH1F - Culturally and Linguistically Appropriate Services (2 points)
PCMH1G - The Practice Team (4 points)
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
PCMH2A - Patient Information (3 points)
PCMH2B - Clinical Data (4 points)
PCMH2C - Comprehensive Health Assessment (4 points)
PCMH2D - Use Data for Population Management (Must Pass) (5 points)
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.
PMCH3A - Implement Evidence-Based Guidelines (4 points)
PMCH3B - Identify High Risk Patients (3 points)
PMCH3C - Care Management (Must Pass) (4 points)
PMCH3D - Medication Management (3 points)
PMCH3E - Use Electronic Prescribing (3 points)
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.
PMCH4A - Support Self-Care Process (Must Pass) (6 points)
PMCH4B - Provide Referrals to Community Resources (3 points)
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.
PMCH5A - Test Tracking and Follow-Up (6 points)
PMCH5B - Referral Tracking and Follow-Up (Must Pass) (6 points)
PMCH5C - Coordinate With Facilities and Care Transitions (6 points)
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.