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Team-Based Care and Practice Organization (TC)

The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.

PCMH Transformation Leads (TC 01)

Designates a clinician lead of the medical home and a staff person to manage the PCMH transformation and medical home activities.

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Structure and Staff Responsibilities (TC 02)

Defines practice organizational structure and staff responsibilities/skills to support key PCMH functions.

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External PCMH Collaborations (TC 03)

The practice is involved in external PCMH-oriented collaborative activities.

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Patients/Families/Caregivers Involvement in Governance (TC 04)

Patients/families/caregivers are involved in the practice’s governance structure or on stakeholder committees.

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Certified EHR System (TC 05)

The practice uses a certified electronic health record technology system (CEHRT).

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Individual Patient Care Meetings/Communication (TC 06)

Has regular patient care team meetings or a structured communication process focused on individual patient care.

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Staff Involvement in Quality Improvement (TC 07)

Involves care team staff in the practice's performance evaluation and quality improvement activities.

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Behavioral Health Care Manager (TC 08)

Has at least one care manager qualified to identify and coordinate behavioral health needs.

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Medical Home Information (TC 09)

Has a process for informing patients/families/caregivers about the role of the medical home and provides patients/families/caregivers materials that contain the information.

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