FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.21.2018 TC 01 Does the clinician lead and staff managing the medical home transformation need to be an MD?

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

5.21.2018 TC 06 Are practices required to have daily, structured meetings with the entire care team? Is the clinician required to attend?

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

11.09.2017 Additional Resources Are there any outside resources that may help me in the PCMH transformation process?

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