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)

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.