Problem Lists: Documents an up-to-date problem list for each patient with current and active diagnoses
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.
Problem Lists: Documents an up-to-date problem list for each patient with current and active diagnoses
Conducts depression screenings for adults and adolescents using a standardized tool.
Conducts behavioral health screenings and/or assessments using a standardized tool.
Assesses oral health needs and provides necessary services during the care visit based on evidence-based guidelines or coordinates with oral health partners.
Identifies the predominant conditions and health concerns of the patient population.
Understands social determinants of health for patients, monitors at the population level and implements care interventions based on these data.
Evaluates patient population demographics/communication preferences/health literacy to tailor development and distribution of patient materials.
Assesses the diversity (race, ethnicity, and one other aspect of diversity) of its population.
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