PCMH Standard 4 Deborah Johnson Ingram
Patient Centered Medical Home 2011 Standards
Recap of PCMH Standard 3 PCMH Standard 3: Plan and Manage Care Practice implements evidence-based guidelines System to identify high-risk patients Care team performs care management through pre-visit planning, developing plan and treatment goals
Recap of PCMH Standard 3 PCMH STANDARD 3 INFORMS YOUR GOALS FOR PCMH STANDARD 4 PCMH Standard 3 PCMH Standard 4 Comprehensive Chronic Disease Health Care Delivery
PCMH Standard 4 Element A Critical factor
PCMH Standard 4 Element A Factor 1 Need to show proof of documented educational resources Brochures Handout materials Videos Weblinks Referral to resources outside the practice (covered and not covered by ins) Disease specific self-management programs
PCMH Standard 4 Element A Factor 2 EXAMPLE: List of DM w/ uncontrolled BP will get a Pt. Ed materials related to the importance of maintaining a controlled BP as a risk factor related to DM remember to tabulate the # of patients receiving pt. ed. materials
PCMH Standard 4 Element A Factor 3
PCMH Standard 4 Element A Factors 4&5 Factor 5 Factor 4
PCMH Standard 4 Element A Factor 6
PCMH 4A Self Care Support and Community Resources There are two method for collecting data for these elements. Method 1. Query your electronic medical records or other electronic patient records to obtain the information for the important conditions identified in PCMH 3: Elements A and the high-risk or complex patients identified in PCMH 3: Element B to calculate the percentage directly. If you can use Method 1 (above) to respond to these elements, you can enter the responses directly into the Survey Tool and you do not need to use this Record Review Workbook. Method 2. Review a sample of 48 patient records to obtain the information. (Note: Patient records may be a registry or electronic records or paper medical records.) Refer to each element in the PCMH 2011 standards for details about scoring PCMH 3C, 3D, and 4A. If you cannot use Method 1, you must use Method 2 to respond to these elements and must fill out the Patient Conditions and Record Review Worksheets. You may respond to some elements with Method 1 and others with Method 2.
PCMH 4A Selecting Conditions and Requisite # s 2. Number of Patients Select the 48 patients who have any one or more of the three chosen clinically important conditions and who had a care visit related to the selected important conditions. These will be the patients used in your medical record review. You will review these same 48 patient files for all of the elements in this Record Review Workbook. Each of the three important conditions and the high-risk or complex patients must be equally represented. There must always be a total of 48 patients. * 4 Conditions: If the practice identified high-risk patients in 3B, these patients should be included in the Workbook in addition to the 3 important conditions identified in 3A. There must be 12 patients from each of the 3 important conditions plus 12 high risk patients. * 3 Conditions: The important conditions should have an equal number of patients. There must be 16 patients which may be three conditions identified in 3A OR two important conditions identified in 3A (including one unhealthy behaviors or substance abuse or mental health condition) plus the high-risk or complex patients identified in 3B. * 2 Conditions: If the practice chooses only two important conditions in 3A (including one unhealthy behavior or substance abuse or mental health condition), 24 patients must be used for each important condition.
PCMH 4A Selecting Conditions and Requisite # s
PCMH Record Review Workbook
PCMH Record Review Workbook
PCMH Standard 4 Element B
PCMH Standard 4 Element B Documentation
PCMH Standard 4 Element B Factor 1 Maintain a current community resource. List has to cover 5 topics
PCMH Standard 4 Element B Factor 2 Track referrals to community resources
PCMH Standard 4 Element B Factor 3 &4 Need a documented process and 1 example