PCC PCMH Resources

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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)

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)

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)

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)

PMCH6A - Measure Performance (4 points)

PMCH6B - Measure Patient/Family Experience (4 points)

PMCH6C - Implement Continuous Quality Improvement (Must Pass) (4 points)

PMCH6D - Demonstrate Continuous Quality Improvement (3 points)

PMCH6E - Report Performance (3 points)

PMCH6F - Report Data Externally (2 points)

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