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Knowing and Managing Your Patients (KM)

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.

Community Resource Needs (KM 21)

Uses information on the population served by the practice to prioritize needed community resources.

Sample

Access to Educational Resources (KM 22)

Provides access to educational resources, such as materials, peer-support sessions, group classes, online self-management tools or programs.

Sample

Oral Health Education (KM 23)

Provides oral health education resources to patients.

Sample

Shared Decision-Making Aids (KM 24)

Adopts shared decision-making aids for preference- sensitive conditions.

Sample

School/Intervention Agency Engagement (KM 25)

Engages with schools or intervention agencies in the community.

Sample

Community Resource List (KM 26)

Routinely maintains a current community resource list

Sample

Community Resource Assessment (KM 27)

Assesses the usefulness of identified community support resources.

Sample

Case Conferences (KM 28)

Has regular “case conferences” involving parties outside the practice team

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