ALLIANCE FAQ PATIENT-CENTERED MEDICAL HOME (PCMH)
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilALLIANCE FAQ – PATIENT-CENTERED MEDICAL HOME (PCMH) 2014 CONTENTOverview: This FAQ is to inform you of new and revised Alliance Clinical Content for use in implementing PCMH 2014 Standards & Guidelines. The PCMHelements referenced in this FAQ are based on the National Committee for Quality Assurance (NCQA) PCMH model. Each clinical content item will be displayed,along with the related PCMH 2014 element/factor and workflow recommendations for use.How can I access this clinical content?This content is already available in your Centricity EHR database. Please contact your EHR Team at your Health Center for help on embedding this content intoyour standard clinical workflows. This includes setting up your Favorites, Document Templates, and Encounter Types that contain this content.How do I suggest an improvement or change to this content?As with any Alliance Clinical Content item, there is always room for improvement. We fully anticipate that you will think of ways to improve and advance thiscontent further as you continue to use this in your PCMH workflows.Suggested Process for Content Change Requests Use the content first, consistently, in your PCMH workflows. Using the content with real, live patients, in partnership with your clinical care team, willbest inform you as a health center on what you want to improve in the content. Submit the request to your EHR Team per your standard content request process. The EHR Team should review this request with your Medical Director, to ensure that the request meets the needs of your organization as a whole. Once this is approved by your Medical Director, submit this request through the Alliance Help Desk.We look forward to your feedback!Thank you,The Alliance of Chicago Clinical Team1
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContentNamePhone Note2014 PCMHStandard1: PatientCenteredAccess1: PatientCenteredAccess2014 PCMHElement1B: 24 Accessto ClinicalAdvice1B: 24 Accessto ClinicalAdvice2014 PCMH Factor1B2: Providing timely clinical advice bytelephone (24 hours – whether it’s opened orclosed). Critical Factor1B4: Documenting clinical advice in patientrecords.2011Crosswalk1A2 & 1B31A4 & 1B5Workflow NotesDocument any clinical advice in the “Details” text box and checkthe “Clinical advice provided” box.Document any clinical advice in the “Details” text box.If the call was after-hours, mark the “after hours” checkbox.1B2 & 1B41B2 & 1B42
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContent Name2014 PCMHStandard5: CareCoordinationand CareTransitions2014 PCMHElement2014 PCMH Factor5B: ReferralTracking &Follow-Up(Must Pass)5B7: Has the capacity for electronicexchange of key clinical information andprovides an electronic summary of carerecord to another provider for more than50 percent of referrals.5C: CoordinateCareTransitions5C7: Exchanges key clinical informationwith facilities and provides an electronicsummary-of-care record to another carefacility for more than 50 percent ofpatient transitions of care.CentricityReferral Orders2011Crosswalk5B6 & 5B7 5C7 & 5C85: CareCoordinationand CareTransitionsWorkflow Notes This is used when Health Centers are managing their referrals. Oneway to get there:o Chart Summary Orders Referrals ChangeHealth Centers set up their Transitions of Care Outbound in theOrders section in the Administration Module.Select the checkbox “Create Transition of Care Document” and hit“Save & Create” buttonThis is used when Health Centers are managing their referrals. Oneway to get there:o Chart Summary Orders Referrals ChangeHealth Centers set up their Transitions of Care Outbound in theOrders section in the Administration Module.Select the checkbox “Create Transition of Care Document” and hit“Save & Create” button5B7 & 5C73
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContent Name2014 PCMHStandard2: TeamBased Care5: CareCoordination& CareTransitions5: CareCoordination& CareTransitionsPre-VisitPreparation5: CareCoordination& CareTransitions5: CareCoordination& CareTransitions5: CareCoordination& CareTransitions5: CareCoordination& CareTransitions2014 PCMHElement2A: PracticeTeam5A: TestTracking &Follow Up5A: TestTracking &Follow Up2014 PCMH Factor2A1: Assistingpatients/families to select apersonal clinician anddocumenting the selection inpractice records.5A1: Tracks lab tests untilresults are available, flaggingand following up on overdueresults (Critical Factor)5A2: Tracks imaging testsuntil results are available,flagging and following up onoverdue results (CriticalFactor)5A: TestTracking &Follow Up5A3: Flags abnormal results,bringing them to theattention of the clinician5B: ReferralTracking &Follow Up(Must Pass)5B8: Tracks referrals until theconsultant or specialist’sreport is available, flaggingand following up on overduereports. (Critical Factor)5B: ReferralTracking &Follow Up(Must Pass)5B10: Askingpatients/families about selfreferrals & requesting reportsfrom clinicians5C: CoordinateCare Transitions5C1: Proactively identifiespatients with unplannedhospital admissions andemergency department visits2011Crosswalk1D1 & 1D2Workflow NotesWhile the documentation of the clinician choice is in the Responsible Provider field,mark the “Choice of provider given.” checkbox in the Provider Choice section toindicate that you gave the patient a choice.5A1 5A2 5A3 5B2 & 5B3 5B5 Document any pertinent notes in the “Lab/Img/Tst Results” field in the ChartReview section.Mark the “Lab, imaging, and test results reviewed.” checkbox in the ChartReview section to indicate that you reviewed these tests.Document any pertinent notes in the “Lab/Img/Tst Results” field in the ChartReview section.Mark the “Lab, imaging, and test results reviewed.” checkbox in the ChartReview section to indicate that you reviewed these tests.Document any pertinent notes in the “Lab/Img/Tst Results” field in the ChartReview section.Mark the “Lab, imaging, and test results reviewed.” checkbox in the ChartReview section to indicate that you reviewed these tests.Document any pertinent notes in the “Referrals” field in the Chart Reviewsection.Mark the “Referrals reviewed.” checkbox in the Chart Review section toindicate that you reviewed these tests.Document any pertinent notes in the “Referrals” field in the Chart Reviewsection.Select the checkbox where it says “Request for health information sent to otherhealthcare provider” on the Pre-Visit Preparation tab.Document any pertinent notes in the Referral Tracking & Follow Up5C1Document any pre-visit processes using the “Healthcare History” section.4
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilUse the “Previous” and “Check All” buttonsfor efficient charting as appropriate.Pre-Visit Preparation: any chart reviewperformed prior to the day of the office visit.2A15C15B105A1-3,5B8,5B105
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContentNameTeamHuddles2014 PCMHStandard2014 PCMHElement2014 PCMH Factor2D3: Holding scheduled patient careteam meetings or a structuredcommunication process focused onindividual patient care. (CriticalFactor)2: EnhanceAccess &Continuity2D: ThePractice Team5: Track &CoordinateCare5A: TestTracking &Follow Up5: Track &CoordinateCare5A: TestTracking &Follow Up5: Track &CoordinateCare5A: TestTracking &Follow Up5A3: Flags abnormal results,bringing them to the attention ofthe clinician5B: ReferralTracking &Follow Up(Must Pass)5B: ReferralTracking &Follow Up(Must Pass)5C: CoordinateCareTransitions5B8: Tracks referrals until theconsultant or specialist’s report isavailable, flagging and following upon overdue reports. (Critical Factor)5: Track &CoordinateCare5: Track &CoordinateCare5: Track &CoordinateCare2011Crosswalk1G25A1: Tracks lab tests until resultsare available, flagging and followingup on overdue results (CriticalFactor)5A2: Tracks imaging tests untilresults are available, flagging andfollowing up on overdue results(Critical Factor)5B10: Asking patients/familiesabout self-referrals & requestingreports from clinicians5C1: Proactively identifies patientswith unplanned hospital admissionsand emergency department visits.Workflow Notes 5A1 5A2 5A3 5B2 & 5B3 If you want to use the EHRS to document this process, use this form. Please notethat this requires you to conduct a “Team Huddle” visit for each patient’selectronic chart, since Centricity does not allow group documentation that canauto-save to multiple patient charts with one charting of the document.If using the EHRS to document this process, set up the “Team Huddle” form in aseparate Document Template and Encounter Type titled with the same name, sothat you can then report on how often these were conducted.Document any pertinent notes in the “Lab/Img/Tst Results” field in the ChartReview section.Mark the “Lab, imaging, and test results reviewed.” checkbox in the Chart Reviewsection to indicate that you reviewed these tests.Document any pertinent notes in the “Lab/Img/Tst Results” field in the ChartReview section.Mark the “Lab, imaging, and test results reviewed.” checkbox in the Chart Reviewsection to indicate that you reviewed these tests.Document any pertinent notes in the “Lab/Img/Tst Results” field in the ChartReview section.Mark the “Lab, imaging, and test results reviewed.” checkbox in the Chart Reviewsection to indicate that you reviewed these tests.Document any pertinent notes in the “Referrals” field in the Chart Review section.Mark the “Referrals reviewed.” checkbox in the Chart Review section to indicatethat you reviewed these tests.Document any pertinent notes in the “Referrals” field in the Chart Review section.5B5Document any pertinent notes in the “Referrals” field in the Chart Review section.5C1Document any pre-visit processes using the “Healthcare History” section.6
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilTeam Huddle: any chart review performed themorning of the office visit.2D35B105A1-3,5B8,5B105C17
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContentName2014 PCMHStandard3: PopulationManagement4: CareManagementSupportInitial Intake2014 PCMHElement3C:ComprehensiveHealthAssessment4C: MedicationManagement4: CareManagementSupport4C: MedicationManagement5: CareCoordinationand Transition5B: ReferralTracking &Follow Up (MustPass)5: Track &CoordinateCare5C: CoordinateCare Transitions2014 PCMH Factor2011Crosswalk2C3Workflow NotesDocument any pertinent information in the “Patient Learning & Communication Needs”section.3C3: Communication needs4C1: Reviews and reconcilesmedications for more than50 percent of patientsreceived from caretransitions. CRITICALFACTOR4C2: Reviews and reconcilesmedications withpatients/families for morethan 80 percent of caretransitions.3D15B10: Asks patients/familiesabout self-referrals andrequesting reports fromclinicians.5C1: Proactively identifiespatients with unplannedhospital admissions andemergency departmentvisits.5B5 3D2 Mark a Transition of Care, Inbound in the Transitions of Care section.If checked, a reminder will appear in the form to “Perform Medication Reconciliation”with easy access to the Centricity Medications functionality.Review the patient’s medication list and then document that it was complete byselecting the checkbox, “Medication List reviewed today, including over-thecounter/herbal/supplement meds”Mark a Transition of Care, Inbound in the Transitions of Care section.If checked, a reminder will appear in the form to “Perform Medication Reconciliation”with easy access to the Centricity Medications functionality.Review the patient’s medication list and then document that it was complete byselecting the checkbox, “Medication List reviewed today, including over-thecounter/herbal/supplement meds”Document any pertinent notes in the “Referrals” field in the Chart Review section.5C1Document any pre-visit processes using the “Healthcare History” section.8
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilInitial Intake: any documentation not considered a traditional“vital sign” but performed when the patient is roomed.4C1 & 4C25C15B103C34C1 & 4C29
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContentNameAdult CC/HPIPediatricCC/HPI2014 PCMHStandard2014 PCMHElement4: CareManagementSupport4C: MedicationManagement4: CareManagementSupport4C: MedicationManagement2014 PCMH Factor4C1: Reviews and reconcilesmedications for more than 50percent of patients received fromcare transitions. Critical Factor4C2: Reviews and reconcilesmedications with patients/familiesfor more than 80 percent of caretransitions.2011Crosswalk3D13D2Workflow Notes Mark a Transition of Care, Inbound in the Transitions of Care section.Review the patient’s medication list and then document that it was complete byselecting the checkbox, “Medication List reviewed today, including over-thecounter/herbal/supplement meds”Mark a Transition of Care, Inbound in the Transitions of Care section.Review the patient’s medication list and then document that it was complete byselecting the checkbox, “Medication List reviewed today, including over-thecounter/herbal/supplement meds”4C1 & 4C24C1 & 4C210
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContentNameQuality ofCareChecklist –MU Tab2014 PCMHStandard2014 PCMHElement4: CareManagementSupport4C: MedicationManagement4: CareManagementSupport4C: MedicationManagement2014 PCMH Factor4C1: Reviews and reconcilesmedications for more than 50percent of patients received fromcare transitions. Critical Factor4C2: Reviews and reconcilesmedications with patients/familiesfor more than 80 percent of caretransitions.2011Crosswalk3D13D2Workflow Notes Select checkbox “Reviewed” next to Medications on the Quality of Care Checklistunder the MU Tab Select checkbox “Reviewed” next to Medications on the Quality of Care Checklistunder the MU Tab4C1 & 4C211
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContent NameCareManagementPlan2014 PCMHStandard2014 PCMH Element2: Team BasedCare2B: Medical HomeResponsibilities2: Team BasedCare2B: Medical HomeResponsibilities4: CareManagementand Support4: CareManagementand Support4: CareManagementand Support4: CareManagementand Support4B: Care Planning andSelf Care Support(Must Pass)4B: Care Planning andSelf Care Support(Must Pass)4B: Care Planning andSelf Care Support(Must Pass)4: CareManagementand Support4: CareManagementand Support4: CareManagementand Support4: CareManagementand Support4C: MedicationManagement4C: MedicationManagement4C: MedicationManagement4B: Care Planning andSelf-Care Support(Must Pass)4E: Support Self-Careand Decision Making2014 PCMH Factor2B1: The practice is responsible forcoordinating patient care acrossmultiple settings.2B4: The care team providesaccess to evidence-based care,patient/family education and selfmanagement support.2011Crosswalk1E1Use this form as one of your primary resources for both accessing anddocumenting the patient’s care plan.1E4Mark the “Patient education offered for care management plan support.”checkbox in the Self-Care Assessment section as appropriate.New4B2: Identifies treatment goals.4B5: Is provided in writing to thepatient/family/caregiver.Workflow Notes3C34B3: Assesses and addressespotential barriers to meetinggoals.4C3: Provides information aboutnew prescriptions to more than 80percent ofpatients/families/caregivers.4C4: Assesses understanding ofmedications for more than 50percent ofpatients/families/caregivers, anddates the assessment.4C5: Assesses response tomedications and barriers toadherence for more than 50percent of patients, and dates theassessment.4B4: Includes a self-managementplan.3C44E3: Provides self-managementtools to record self-care results4A5Use the Provider Care Plan field to document the treatment goals for thepatient.Any self-management goals charted from this form can be printed using the“Print Care Management Plan” button.Document barriers information in the Self-Care Assessment section.3D33D4Document the providing of new prescription information by marking the“Information on new prescriptions provided to patient/family.” checkbox inthe Medication Adherence & Education section. 3D5 Document any pertinent notes in the “Understanding of meds” field inthe Medication Adherence & Education section.Mark the “Assessed patient/family understanding of medications.”checkbox in the Medication Adherence & Education section.Document any pertinent notes in the “Barriers to taking meds” field in theMedication Adherence & Education section.Mark the “Assessed patient response to medications & potential barriersto adherence.” checkbox in the Medication Adherence & Educationsection.NewUse this form to chart self-management plans/goals.Mark the “Provided self-management tools to record self-care results”checkbox in the Self-Care Assessment section when you provided said tools.12
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 April2B14B24B44C34C44C54C54B34E32B44B513
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContentNameAllianceActiveReferralsHistory View2014 PCMHStandard5: Track &CoordinateCare2014 PCMHElement5B: ReferralTracking &Follow Up (MustPass)2014 PCMH Factor5B8: Tracks referrals until theconsultant or specialist’s report isavailable, flagging and following upon overdue reports. (CriticalFactor)2011Crosswalk5B2 & 5B3Workflow NotesUse this History View to further track any active referrals for the patient.14
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & ContentUpdated: 2016 AprilContentNameAllianceFlowsheet:AlliancePCMH RRWB2014 PCMHStandardsVarious 2014 PCMHStandards for yourMedical RecordWorkbook Review!2014 PCMH ElementElements 1, 2, 3, 42014 PCMH FactorsVarious 2014 PCMHFactors for yourMedical RecordWorkbook Review!2011Crosswalk-Workflow NotesUse this Alliance Flowsheet to further track appropriate documentation and preparefor the audits for various PCMH factors, including the Medical Record WorkbookReview!15
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2014 Standards & Content Updated: 2016 April ALLIANCE FAQ – PATIENT-CENTERED MEDICAL HOME (PCMH) 2014 CONTENT Overview: This FAQ is to inform you of new and revised Alliance Clinical Content for use in implementing PCMH 2014 Standards & Guidelines.The PCMH elements referenced in this FAQ are based on the National
Alliance FAQ – Patient-Centered Medical Home (PCMH) 2017 Standards & Content Updated: 2018 MAY ALLIANCE FAQ – PATIENT-CENTERED MEDICAL HOME (PCMH) 2018 CONTENT Overview: This FAQ is to inform you of new and revised Alliance Clinical Content for use in implementing PCMH 2017 Standards & Guidelines.The PCMH el
Revised July 2017 PCMH CEC Handbook Patient-Centered Medical Home Content Expert Certification Overview The patient-centered medical home (PCMH) is a health care setting that facilitates partnerships between individual patients and their personal clinicians, and when appropriate, the patient’s family. Care is facilitated by registries,
The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change; organizes some of the evidence that is foundational to the PCMH concept and identifies key elements of a medical home for delivering a patient-centered experience Distinguish the standards for meeting specific PCMH elements
Textbook Update Fall 2016 COURSE OUTLINE Patient Centered Care in Mental Health and High Acuity Medical-Surgical Environments Course Description NR 202 Patient Centered Care in Mental Health and High Acuity Medical-Surgical Environments. 9 hours credit. Prerequisites: AH
B- La Bible est l'alliance de Dieu avec les humains, composée d'une Ancienne Alliance et d'une Nouvelle Alliance. C- L'Ancienne Alliance est dévoilée dans le Nouveau Testament. Le Nouveau Testament est caché dans l'Ancienne Alliance. L'Ancienne Alliance contient des types et des ombres du Nouveau Testament.
KOLCABA'S COMFORT THEORY AND PATIENT CENTERED CARE 9 to my case study, the salient concepts are uncertainty of illness resulting in pre-operative anxiety, health seeking behaviors identified through observation and patient nurse dialogue, and providing comfort through patient centered care and
The patient-centered design of Wexford Hospital includes a variety of unique facility and technology features such as the rooftop garden, smart television, mobile app, and patient room control. The purpose of this paper is to evaluate the patient-centered design of Wexford Hospital by comparing the various features as well as the
1 Units as a measure of Risk 16 The Origin of the Free Rules Project 1 The Ugly Truth about the System Sellers 2 C H A P T E R 4 Rules You Won’t Follow Don’t Matter 3 Entries 19 The Genesis of the Project 4 Breakouts 19 Adding Units 20 I N T R O D U C T I O N Consistency 21 The Turtle Experiment 6 C H A P T E R 5 C H A P T E R 1 Stops 22 A Complete Trading System 8 Turtle Stops 22 The .
