Standard Pcmh 1 Enhance Access Continuity
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Six Standards for NCQA PCMH Enhance Access & Continuity Identify & Manage Patient Populations Plan & Manage Care Provide Self-Care & Community Support Track & Coordinate Care Measure & Improve Performance
Enhance Access & Continuity PCMH Element 1 F: Culturally and linguistically appropriate services Factor 1 F 1: Assess the racial and ethnic diversity of its population Factor 1 F 2: Assess the language needs of its population Factor 1 F 3: Provides interpretation or bilingual services to meet the language needs of its population Factor 1 F 4: Provides printed materials in the languages of its population
Enhance Access & Continuity PCMH Element 1 G: The practice team Factor 1 G 5: Training and assigning care teams to support patients and families in selfmanagement, self-efficacy and behavior change Factor 1 G 6: Training and assigning care teams for patient population management Factor 1 G 6: Training and designating care team members in communication skills
Enhance Access & Continuity Explain medical home in Provide regular source of culturally and linguistically appropriate way Ensure language access Expand "after hours" access Hire care team that reflects patient population Use multiple channels and formats for communication, including e-health and mobile health care Provide expanded access, same-day appointments Facilitate communication with entire care team Provide electronic access for appointments, refills, test results
Identity & Manage Patient Populations PCMH Element 2 A: Use electronic system to record the following as structured (searchable) data for more than 50% of its patients: Factor 2 A 3: Race Factor 2 A 4: Ethnicity Factor 2 A 5: Preferred language PCMH Element 2 C: Comprehensive health assessment includes: Factor 2 C 2: Family/social/cultural characteristics Factor 2 C 3: Communication needs
Identity & Manage Patient Populations Empanel or assign patients Match patient preferences for to primary care provider/teams Document granular Document demographic and demographic information clinical data electronically (race, ethnicity, language) Use clinical decision support Identify and address barriers to provide evidence-based care for vulnerable populations, including health literacy Use standing orders and electronic prescribing Implement culturally and Identify high risk and high linguistically appropriate need patients that need interventions to reduce more support (registries) disparities
Plan & Manage Care Develop individual care Ensure culturally and plan, with individual goals Engage patient, family, caregivers in care plan Support shared decisionmaking about care Send reminders to patients and use provider alerts Identify and respond to needs of high-risk, complex patients linguistically appropriate care plan Identify and address barriers for vulnerable populations, including health literacy Provide culturally and linguistically appropriate tools to patient, families, and caregivers
Provide Self-Care & Community Support PCMH Element 4 A: Support self-care process Factor 4 A 1: Provides educational resources or refers at least 50% of patients/families to educational resources to assist in self-management Factor 4 A 2: Uses an EHR to identify patient-specific education resources and provide them to >10% patients, if appropriate PCMH Element 4 B: Provides referrals to community resources Factor 4 B 1: Maintains a current resource list on 5 topics or key community service areas of importance to the patient population
Provide Self-Care & Community Support patient education Support patient self- management Share summaries of care Provide access to health information Engage families and caregivers Provide referrals to community resources Ensure patient education is culturally and linguistically appropriate Address health literacy Provide access to health information in multiple languages, channels, formats Include community resources focused on diverse communities
Track & Coordinate Care Proactively track tests and Ensure culturally and referrals Follow-up directly with patients when tests or referrals not completed Coordinate care with labs, specialists, hospitals, and other providers Ensure coordinated transitions of care Conduct medication reconciliations linguistically appropriate referrals Identify and address barriers for vulnerable populations, including health literacy Engage patients, families, and caregivers in care coordination Share coordination documents with patients
Measure & Improve Performance PCMH Element 6 A: Measure performance Factor 6 A 4: Performance data stratified for vulnerable populations (to assess disparities in care) PCMH Element 6 B: Patient/family feedback Factor 6 B 3: The practice obtains feedback in the experiences of vulnerable populations Factor 6 B 4: The practice obtains feedback from patients/families through qualitative means
Measure & Improve Performance PCMH Element 6 C: Implement continuous quality improvement Factor 6 C 3: Set goals and address at least one identified disparity in care or service for vulnerable populations Factor 6 C 4: Involve patients/families in quality improvement teams or on the practice's advisory council
Measure & Improve Performance Identify and act on Stratify all quality data by opportunities to improve race, ethnicity, and language quality Identify and reduce Measure and improve disparities patient experience of care Oversample vulnerable Publicly report quality patients for feedback on measures experience of care Seek continuous quality Improve patient experience improvement of care for vulnerable patients Engage diverse patients in quality improvement efforts
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