PCC PCMH Resources
What is this page all about? Why did we create it? Who is it for?
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.