PCMH3A
The practice maintains continuous relationships with patients through care management processes based on evidence-based guidelines. A key to successful implementation of guidelines is to embed them in the practice’s day-to-day operations and by using registries that proactively identify and engage patients who are lacking important services (as in PCMH 2, Element D).
The practice implements evidence-based guidelines through point of care reminders for patients with 3 important conditions.
When selecting conditions, you should consider the following:
- Diagnoses and risk factors prevalent in patients seen by the practice (data from PCMH 2, Elements B and C)
- Pick conditions where care management, medication management, and self-management support play a role in reducing complications
- Pick conditions for which there are evidence-based clinical guidelines
- Patients with the conditions selected in factors 1–3 will be used for the medical record review required in Elements 3.C and 3.D, and in PCMH 4, Element A.
3.A.1 The first important condition
| Description | Example/Screenshot/Documentation | Source | Date Added |
|---|---|---|---|
| Corporate diagram, job descriptions, and weekly administrative schedule | Asthma Example | TPC | 03/25/13 |
3.A.2 The second important condition
| Description | Example/Screenshot/Documentation | Source | Date Added |
|---|---|---|---|
| Corporate diagram, job descriptions, and weekly administrative schedule | Well Child Example | TPC | 03/25/13 |
At least one identified condition must be related to unhealthy behaviors (e.g., obesity, smoking), substance abuse (e.g., drug addiction, alcoholism) or a mental health issue (e.g., depression, anxiety, ADHD).
| Description | Example/Screenshot/Documentation | Source | Date Added |
|---|---|---|---|
| Corporate diagram, job descriptions, and weekly administrative schedule | ADHD Example | TPC | 03/25/13 |