Identifies and addresses population-level needs based on the diversity of the practice and the community
The PCMH model expects continuity of care. Patients/families/caregivers have 24/7 access to clinical advice and appropriate care facilitated by their designated clinician/care team and supported by access to their medical record. The practice considers the needs and preferences of the patient population when establishing and updating standards for access.
Identifies and addresses population-level needs based on the diversity of the practice and the community
Proactively and routinely identifies populations of patients and reminds them, or their families/caregivers about needed services.
Demonstrates excellence in a benchmarked/ performance-based recognition program assessed using evidence-based care guidelines.
Reviews and reconciles medications for more than 80 percent of patients received from care transitions.
Maintains an up-to-date list of medications for more than 80 percent of patients.
Assesses understanding and provides education, as needed, on new prescriptions for more than 50 percent of patients/families/caregivers.
Assesses and addresses patient response to medications and barriers to adherence for more than 50 percent of patients, and dates the assessment.
Reviews a controlled substance database when prescribing relevant medications.
Systematically obtains prescription claims data in order to assess and address medication adherence.
Implements clinical decision support following evidence- based guidelines.
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