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.

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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.

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Oral Health Education (KM 23)

Provides oral health education resources to patients.

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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.

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Community Resource List (KM 26)

Routinely maintains a current community resource list

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Community Resource Assessment (KM 27)

Assesses the usefulness of identified community support resources.

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Case Conferences (KM 28)

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

Sample
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