This criterion requires both a documented process ensuring information is distributed to patients and demonstration of patient materials with the minimum information described in the guidance. However, if the practice's documented process is described in the patient brochure, that brochure could be sufficient evidence for TC 09.
PCMH 2017
TC 06 requires practices to engage in regular communication to discuss care for patients scheduled each day, but this requirement can be satisfied by demonstration of either scheduled team meetings or scheduled electronic team communication, depending on the practice’s process for communication. Please note this communication is focused on patient care needs and is not to discuss practice transformation activities or staffing schedules.
All members of the practice care team, including clinicians, must participate in the communication; however, it is not required that the clinician be present if the team meets in-person, as long as there is a process in place to communicate the information from the meeting to the clinician.
PCMH 2017
The clinician lead of the medical home must be a clinician as defined in the PCMH Policies and Procedures, which includes clinicians with an unrestricted license as an MD, DO, APRN or PA; however, NCQA is not prescriptive regarding the staff member who can be designated as the PCMH manager. Both can serve multiple sites and both roles can be assumed by the same person.
PCMH 2017
The requirement is met if teams share questions or concerns about shared patients via regular, structured communication (such as the EHR). The intent of the criterion is for all members of the care team to be involved in communication about patient care, but care teams can meet separately for each clinician’s scheduled patients.
PCMH 2017
| Content Area | Criteria | Resource Link | Description |
| TC | 02 | http://www.ihi.org/resources/Pages/Changes/OptimizetheCareTeam.aspx | Resource on how to optimize staff responsibilities |
| 02 | https://www.integration.samhsa.gov/operations-administration/OATI_Tool3_ART.pdf | Toolkit on how to optimize administrative staff responsibilities to benefit clinical practice | |
| 02 | http://www.improvingprimarycare.org/team/pcp | Resource on how to optimize staff responsibilities | |
| 04 | https://www.stepsforward.org/modules/pfac | Module teaching how to create a patient advisory council | |
| 07 | http://www.nachc.org/research-and-data/prapare/toolkit/ | Toolkit to better understand social determinants of health | |
| 08 | https://integrationacademy.ahrq.gov/sites/default/files/AHRQ_AcademyGuidebook.pdf | Information on behavioral healthcare integration in primary practice | |
| KM | 02 G | https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/ | Social needs screening toolkit |
| 12 | https://www.cdc.gov/media/releases/2012/p0614_preventive_health.html | Discussion on benefits of preventative care | |
| 14 | https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf | Guide to medication reconciliation at transitions | |
| 16 | http://www.teachbacktraining.org/ | Information on teach back training | |
| 17 | http://www.improvingprimarycare.org/work/medication-management | Guide to medication management | |
| 24 | https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html | Toolkit for shared decision making | |
| 24 | http://msdmc.org/3-assess/ | Toolkit for shared decision making | |
| 24 | https://shareddecisions.mayoclinic.org/ | Informative website about shared decision making | |
| 13 | http://www.jabfm.org/content/28/2/170.full.pdf | "Patient Empanelment: The Importance of Understanding Who Is at Home in a Medical Home" | |
| AC | 13 | http://www.annfammed.org/content/10/5/396.full | "Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation" |
| http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/aug/1764_hong_caring_for_high_need_high_cost_patients_ccm_ib.pdf | Article discussing benefits and strategies to care management | ||
| CM | 03 | https://nf.aafp.org/Shop/practice-transformation/risk-stratified-care-mgmt-rubric | Risk stratification rubric available to members of the AAFP |
| 03 | http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdf | Risk stratification rubric from California Quality Collaborative | |
| 03 | http://www.millimanriskadjustment.com/ | MARA – The Milliman Advanced Risk Adjuster is a model of risk stratification in which risk scores are normalized to a given population. | |
| 04 | http://www.aafp.org/fpm/2015/0100/fpm20150100p7-rt1.pdf | Care Plan template from AAFP, not exclusive to members | |
| 06 | http://www.dartmouthatlas.org/downloads/reports/preference_sensitive.pdf | Resource on how to incorporate patient preference into care management | |
| 08 | http://www.ihi.org/resources/pages/tools/selfmanagementtoolkitforclinicians.aspx | Toolkit to aid clinicians in promoting self-management | |
| 08 | https://www.ahrq.gov/professionals/prevention-chronic-care/improve/self-mgmt/index.html | Resources on self management | |
| 08 | http://champsonline.org/tools-products/clinical-resources/patient-education-tools/patient-self-management-tools | Condition specific self management tools | |
| 08 | https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/ | Article discussing proper communication between primary and specialist clinicians | |
| CC | 14 | http://nihcr.org/analysis/improving-care-delivery/prevention-improving-health/ed-coordination/ | Information on improving communication between emergency and primary physicians |
| 16 | https://share.kaiserpermanente.org/article/kaiser-permanente-study-finds-tailored-post-hospital-visits-lower-risk-readmission-medicare-advantage-patients/ | Article discussing advantages of post hospital primary care visits | |
| QI | https://www.ahrq.gov/sites/default/files/publications/files/pcmhqi2.pdf | Resource for building quality improvement in primary care | |
| 03 | http://www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx | Information on how to utlize third next available appointment measurement | |
| 08 | https://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod4.html | Benefits of PDSA cycle |
PCMH 2017
