PCMH Planner Outline- PCMH 101

PCMH 101

The outline below shows what topic areas are covered in the PCMH 101 initiative of the PCMH Planner.

Goal: Practice Organization

1. Objective: Culture of Change 

  • Establish a PCMH Transformation Team and Define the Project Goals
  • Develop a Project Plan, Lead Practice Change, and Monitor Progress

2. Objective: Staffing Model to Support PCMH 

  • Understand the Basics of Team-Based Care
  • Define Team Member Roles and Implement Team-Based Care
  • Train and Cross-train Staff on Team-Based Care

Goal: Quality Care

1. Objective: Coordinate Care Across the Medical Neighborhood 

  • Create a Team to Oversee Care Transitions 
  • Coordinate and Monitor Care Transitions with Specialists, Subspecialists, and Facilities
  • Use Performance Measures to Evaluate and Improve Care Transition Processes 
  • Build Linkages and Relationships With Community Resources

2. Objective: Ensure your EHR has Attributes that Support Needed PCMH Functions

  • Learn About Population Health Management
  • Select and Utilize Patient Registries for Population Health Management

Goal: Patient-Centered Care

1. Objective: Ensure Patients’ Access to Care 

  • Same-Day Appointments
  • Extended-Hours Access to Routine and Urgent Care

2. Objective: Support Patient Self-Management

  • Prepare to Implement Patient Self-Management  Support 
  • Assess Patients and Caregivers in Self-Management 
  • Learn How to Use and Develop Patient Care and Action Plans 
  • Consider Home Monitoring for Chronic Conditions 
  • Use Motivational Interviewing to Coach Patients