FAQ Directory: Patient-Centered Medical Home (PCMH)

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