2017 Main

This wiki serves as an informal repository of PCMH documentation related to the 2017 PCMH Standards released in March 2017. Some 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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The 2017 Standards are broken down into six concepts that align with the principles of primary care. Within each concept are competencies which are meant to organize the criteria within each concept area. Criteria are the individual structures, functions and activities that indicate a practice is operating as a medical home.

To achieve recognition under the new PCMH program, practices must:

• Meet all core criteria
• Earn 25 credits in elective criteria across 5 of 6 concepts.

This ensures a minimum set of capabilities and gives practices the flexibility to focus on activities that not only mean the most to their patient population, but are feasible to accomplish with regard to their resources and the resources of their community.

Team-Based Care and Practice Organization (TC)

The intent of this concept is:

Competency A

Practice routinely collects comprehensive data on patients to understand background and health risks of patients. Practice uses information on the population to implement needed interventions, tools and supports for the practice as a whole and for specific individuals.

Competency B

Communication among staff is organized to ensure that patient care is coordinated, safe and effective.

Competency C

The practice communicates and engages patients on expectations and their role in the medical home model of care.

PCMH 2: Team-Based Care (12 points)

The intent of this standard is:

PCMH 3: Population Health Management (20 points)

The practice uses a comprehensive health assessment and evidence-based decision support based on complete patient information and clinical data to manage the health of its entire patient population.

PCMH 4: Care Management and Support (20 points)

Intent of Standard: The practice systematically identifies individual patients and plans, manages and coordinates care, based on need.

PCMH 5: Care Coordination and Care Transitions (18 points)

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

PCMH 6: Performance Measurement and Quality Improvement (20 points)

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