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.

External Panel Review and Reconciliation (AC 14)

Reviews and reconciles panels based on health plan or other outside patient assignments.

Sample

Panel Size Review and Management (AC 13)

Reviews and actively manages panel sizes.

Sample

Continuity of Medical Record Information (AC 12)

Provides continuity of medical record information for care and advice when the office is closed. 

Sample

Patient Visits with Clinician/Team (AC 11)

Sets goals and monitors the percentage of patient visits with the selected clinician or team.         

Sample

Personal Clinician Selection (AC 10)

Practice helps patients/families/ caregivers select or change a personal clinician.

Sample

Equity of Access (AC 09)

Uses information about the population served by the practice to assess equity of access that considers health disparities.

Sample

Two-Way Electronic Communication (AC 08)

Has a secure electronic system for two-way communication to provide timely clinical advice.       

Sample

Electronic Patient Requests (AC 07)

Has a secure electronic system for patients to request appointments, prescription refills, referrals and test results.

Sample

Alternative Appointments (AC 06)

Provides scheduled routine or urgent appointments by telephone or other technology-supported mechanisms.

Sample

Clinical Advice Documentation (AC 05)

Documents clinical advice in patient records and confirms clinical advice and care provided after-hours does not conflict with patient medical record.

Sample
  •  
  • 1 of 2