Here are six standards that must be passed to qualify for PCMH recognition:
Referral Tracking and Follow-up: A medical practice must coordinate referrals by giving the consultant or specialist the clinical reason for the referral and pertinent clinical information, tracking the status of the referral, following up with the specialist for updates, establishing and documenting agreements to co-manage medical records with specialists if necessary, talking to patients about self-referrals, demonstrating capacity for electronic exchange of clinical information, and providing electronic summaries of care to another health care professional.
Use Data for Population Management: A medical practice must use patient information, clinical data, and evidence-based guidelines to generate lists of patients and to proactively remind patients of various services needed, such as necessary medication, preventative care, acute care, and follow-ups for patient not seen recently.
Support Self-Care Process: A medical practice must conduct activities to support patients in self-management. These activities include providing or referring educational resources, using electronic health records (EHR) to identify patient-specific education, developing and documenting self-management plans and goals for patients, and counseling patients to adopt healthy behaviors.
Access During Office Hours: A medical practice must have a written process and defined standards that monitor performance of providing same-day appointments, and timely clinical advice by patient medical records, telephone and electronic messages during office hours.
Care Management: This includes conducting pre-visit preparations, collaborating with patients to develop individualized care plans, giving patients a written plan of care, assessing and addressing barriers when patients have not met treatment goals, providing clinical summaries, identifying benefits of care management, and following up with patients who have not kept important appointments.
Implement Continuous Quality Improvement: A medical practice must implement an ongoing improvement process for the care offered to its patients.
There are many other standards that should be addressed in addition to these “must have” items. It is important for physicians and their practices to become aware of this method of care as patient-centered, value-driven care becomes a constant within the medical community. Those who need assistance meeting the above standards or would like to learn more about becoming PCMH recognized may contact Terri Gonzalez, NCMS Director of Practice Improvement, at 800-722-1350 or firstname.lastname@example.org. The NCMS offers consulting services through PractEssentials to assist physicians and their practices with practice management needs. NCMS members can receive these services at a discounted rate.