Patient Centred Medical Home Self-assessment …...Introduction to the PCMH-A Before you begin The...
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Patient Centred Medical Home Self-assessment (PCMH-A) Practice name: Your name: Date completed:
Transcript of Patient Centred Medical Home Self-assessment …...Introduction to the PCMH-A Before you begin The...
Patient Centred Medical Home
Self-assessment
(PCMH-A)
Practice name:
Your name:
Date completed:
For more information, contact:
p: 1300 699 167e: [email protected]: wnswphn.org.au
Western NSW PHN acknowledges this document has been developed by Northern Queensland PHN and adapted for use in Australia by Wentwest with permission from the following source: Safety Net Medical Home Initiative.
The Patient-Centred Medical Home Assessment Version 4.0.
The MacColl Center for Health Care Innovation at Group Health Research Institute and Qualis Health; Seattle, WA. September 2014.
Western NSW Primary Health Network respectfully acknowledges the Traditional and Historical Owners, past and present, within the lands in
which we work.
2
Introduction to the PCMH-A
Before you begin
The Patient Centred Medical Home Assessment (PCMH-A) is intended to help practices understand their current level of ‘medical homeness’ and identify opportunities for improvement. The PCMH-A can also help practices track progress toward practice transformation when it is completed at regular intervals.
Identify a multidisciplinary group of practice staff
We strongly recommend that the PCMH-A be completed by a multidisciplinary group (e.g. GPs, practice nurses, practice manager, other operations and administrative staff) in order to capture the perspectives of individuals with different roles within the practice and to get the best understanding of ‘the way things really work.’
We recommend that everyone complete the assessment individually, and that you then meet together to discuss the results, produce a consensus version, and develop an action plan for priority improvement areas.
We discourage practices from completing the PCMH-A individually and then averaging the scores to get a consensus score without having first discussed the results as a group. The discussion is a great opportunity to identify opportunities and priorities for PCMH transformation.
The PCMH-A was developed by the MacColl Center for Health Care Innovation at the Group Health Research Institute and Qualis Health for the Safety Net Medical Home Initiative (SNMHI). The PCMH-A was extensively tested by the 65 practices that participated in the SNMHI, including federally qualified health centres (FQHCs), residency practices, and other settings, and is in use in a number of regional and national initiatives.
Have each practice location in your organisation complete an assessment
If your organisation has multiple locations, each practice should complete a separate PCMH-A. Practice transformation, even when directed and supported by practice leaders, happens differently at the practice level. Practice leaders can compare PCMH-A scores and use this information to share knowledge and cross-pollinate improvement ideas.
Consider where your practice is on the PCMH journey
Answer each question as honestly and accurately as possible. There is no advantage to over-estimating item scores and doing so may make it harder for real progress to be apparent when the PCMH-A is repeated in the future. It is fairly typical for teams to begin the PCMH journey with average scores below five for some or all areas of the PCMH-A.
It is also common for teams to initially believe they are providing more patient-centred care than they actually are. Over time, as your understanding of patient-centred care increases and you continue to implement effective practice changes, you should see your PCMH-A scores increase.
3
Patient Centred Medical HomeSelf-assessment Tool
Directions for completing the assessment
Before you begin, please review the guidelines shown at the beginning of each part.1
2For each row, mark the point value that best describes the level of care that currently exists in the practice. The rows in this form present key aspects of patient-centred care.
Each aspect is divided into levels (A through D) showing various stages in development toward a patient-centred medical home. The levels are represented by points that range from 1 to 12. The higher point values within a level indicate that the actions described in that box are more fully implemented.
3 Encourage other members of your practice to also complete the self-assessment.
4
Engagedleadership
1
Data-driven improvement
2
Patient-team partnership
5
Patient empanelment
3
Population management
6
Prompt accessto care
8
Team-based care
4
Continuityof care
7
Comprehensiveness and care
coordination
9
Quality general
practice of the future
10
The 10 Building Blocks of High-Performing Primary Care
The 10 Building Blocks of High-Performing Primary Care is a conceptual model described by Bodenheimer et al. It identifies and describes the essential elements of primary care that facilitate exemplary performance. WNSW PHN, working closely with its general practice leaders and leveraging off international learnings, has used this as a framework to plan and implement its approach to PCMH.
5
Patient Centred Medical HomeSelf-assessment Tool
PCM
H-A
Par
t 1: E
ngag
ed le
ader
ship
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
1.
Prac
tice
prin
cipa
ls…
are
focu
sed
on sh
ort-
term
bus
ines
s pr
iorit
ies.
…vi
sibly
supp
ort a
nd c
reat
e an
in
frast
ruct
ure
for q
ualit
y im
prov
emen
t, bu
t do
not c
omm
it re
sour
ces.
…al
loca
te re
sour
ces a
nd a
ctiv
ely
rew
ard
qual
ity im
prov
emen
t ini
tiativ
es.
……
supp
ort c
ontin
uous
lear
ning
th
roug
hout
the
prac
tice,
revi
ew a
nd a
ct
upon
qua
lity
data
, and
hav
e a
long
-term
st
rate
gy a
nd fu
ndin
g co
mm
itmen
t to
expl
ore,
impl
emen
t and
spre
ad q
ualit
y im
prov
emen
t ini
tiativ
es.
2.
Clin
ical
lead
ers
…in
term
itten
tly fo
cus o
n im
prov
ing
qual
ity.
…ha
ve d
evel
oped
a v
ision
for q
ualit
y im
prov
emen
t, bu
t no
cons
isten
t pro
cess
fo
r get
ting
ther
e.
…ar
e co
mm
itted
to a
qua
lity
impr
ovem
ent p
roce
ss, a
nd so
met
imes
en
gage
team
s in
impl
emen
tatio
n an
d pr
oble
m so
lvin
g.
…co
nsist
ently
cha
mpi
on a
nd e
ngag
e ca
re te
ams i
n im
prov
ing
patie
nt
expe
rienc
e of
car
e an
d cl
inic
al
outc
omes
.
3.
The
prac
tice’s
re
crui
tmen
t an
d tr
aini
ng
proc
esse
s
…fo
cus o
nly
on th
e na
rrow
ly d
efine
d fu
nctio
ns a
nd re
quire
men
ts o
f eac
h po
sitio
n.
…re
flect
how
pot
entia
l new
team
m
embe
rs w
ill a
ffect
the
cultu
re a
nd
part
icip
ate
in q
ualit
y im
prov
emen
t ac
tiviti
es.
…pl
ace
a pr
iorit
y on
the
abili
ty o
f new
an
d ex
istin
g st
aff to
impr
ove
care
and
cr
eate
a p
atie
nt-c
entr
ed c
ultu
re.
…su
ppor
t and
sust
ain
impr
ovem
ents
in
car
e th
roug
h tr
aini
ng a
nd in
cent
ives
fo
cuse
d on
rew
ardi
ng p
atie
nt-c
entr
ed
care
.
4.
The
resp
onsib
ility
fo
r con
duct
ing
qual
ity
impr
ovem
ent
activ
ities
…is
not a
ssig
ned
by le
ader
ship
to a
ny
spec
ific
grou
p.…
is as
signe
d to
a g
roup
with
out
com
mitt
ed re
sour
ces.
…is
assig
ned
to a
n or
gani
sed
qual
ity
impr
ovem
ent g
roup
who
rece
ive
dedi
cate
d re
sour
ces.
…is
shar
ed b
y al
l sta
ff, fr
om p
ract
ice
prin
cipa
ls to
team
mem
bers
, and
is
mad
e ex
plic
it th
roug
h pr
otec
ted
time
to
mee
t and
spec
ific
reso
urce
s to
enga
ge
in q
ualit
y im
prov
emen
t.
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
1a.
Prov
ide
visib
le a
nd su
stai
ned
lead
ersh
ip to
lead
ove
rall
cultu
re c
hang
e as
wel
l as s
peci
fic st
rate
gies
to im
prov
e qu
ality
, spr
ead,
and
sust
ain
chan
ge.
1b.
Ensu
re th
at th
e PC
MH
tran
sfor
mat
ion
effor
t has
the
time
and
reso
urce
s nee
ded
to b
e su
cces
sful
.
1c.
Ensu
re th
at G
Ps a
nd o
ther
pra
ctic
e te
am m
embe
rs h
ave
prot
ecte
d tim
e to
con
duct
act
iviti
es b
eyon
d di
rect
pat
ient
ca
re th
at a
re c
onsis
tent
with
the
med
ical
hom
e m
odel
.
1d.
Build
the
prac
tice’s
val
ues o
n cr
eatin
g a
med
ical
hom
e fo
r pa
tient
s int
o st
aff h
iring
and
trai
ning
pro
cess
es.
6
2a.
Choo
se a
nd u
se a
form
al m
odel
for q
ualit
y im
prov
emen
t.
2b.
Esta
blish
and
mon
itor m
etric
s to
eval
uate
impr
ovem
ent
effor
ts a
nd o
utco
mes
, ens
ure
all s
taff
mem
bers
und
erst
and
the
met
rics f
or su
cces
s.
2c.
Ensu
re th
at p
atie
nts,
fam
ilies
, GPs
, and
car
e te
am m
embe
rs
are
invo
lved
in q
ualit
y im
prov
emen
t act
iviti
es.
2d.
Opt
imise
use
of h
ealth
info
rmat
ion
tech
nolo
gy a
nd
clin
ical
info
rmat
ion
syst
ems s
uch
as P
EN C
linic
al A
udit
Tool
(PEN
CAT)
, for
mal
PD
SA c
ycle
s, or
stra
tifica
tion
of
popu
latio
ns b
y ra
ce/g
ende
r.
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
PCM
H-A
Par
t 2: Q
ualit
y Im
prov
emen
t (Q
I) st
rate
gy
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
5.
Qua
lity
impr
ovem
ent
activ
ities
…ar
e no
t org
anise
d or
supp
orte
d co
nsist
ently
.…
are
cond
ucte
d on
an
ad h
oc b
asis
in
reac
tion
to sp
ecifi
c pr
oble
ms.
…ar
e ba
sed
on a
pro
ven
impr
ovem
ent
stra
tegy
in re
actio
n to
spec
ific
prob
lem
s.…
are
base
d on
a p
rove
n im
prov
emen
t st
rate
gy a
nd u
sed
cont
inuo
usly
in
mee
ting
prac
tice
goal
s.
6.
Perf
orm
ance
m
easu
res
…ar
e no
t ava
ilabl
e fo
r the
pra
ctic
e.…
are
avai
labl
e fo
r the
pra
ctic
e, b
ut a
re
limite
d in
scop
e.…
are
com
preh
ensiv
e—in
clud
ing
clin
ical
, op
erat
iona
l, an
d pa
tient
exp
erie
nce
mea
sure
s—an
d av
aila
ble
for t
he p
ract
ice,
bu
t not
for i
ndiv
idua
l GPs
.
…ar
e co
mpr
ehen
sive—
incl
udin
g cl
inic
al,o
pera
tiona
l, an
d pa
tient
ex
perie
nce
mea
sure
s—an
d fe
d ba
ck to
in
divi
dual
GPs
.
7.
Qua
lity
impr
ovem
ent
activ
ities
are
co
nduc
ted
by
…a
cent
ralis
ed c
omm
ittee
or
depa
rtm
ent.
…to
pic
spec
ific
QI c
omm
ittee
s.…
all c
are
team
s sup
port
ed b
y a
QI
infra
stru
ctur
e.…
care
team
s sup
port
ed b
y a
QI
infra
stru
ctur
e w
ith m
eani
ngfu
l in
volv
emen
t of p
atie
nts a
nd fa
mili
es.
8.
Clin
ical
in
form
atio
n sy
stem
s tha
t op
timise
use
of
info
rmat
ion
…ar
e no
t pre
sent
or i
s bei
ng
impl
emen
ted.
…ar
e in
pla
ce a
nd a
re b
eing
use
d to
ca
ptur
e cl
inic
al d
ata.
…ar
e us
ed ro
utin
ely
durin
g pa
tient
en
coun
ters
to p
rovi
de c
linic
al d
ecisi
on
supp
ort a
nd to
shar
e da
ta w
ith p
atie
nts.
…ar
e al
so u
sed
rout
inel
y to
supp
ort
popu
latio
n m
anag
emen
t and
qua
lity
impr
ovem
ent e
ffort
s.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10 7
PCM
H-A
Par
t 3: P
atie
nt re
gist
ratio
n
3a.
Link
pat
ient
s to
a pr
imar
y G
P an
d co
nfirm
ass
ignm
ents
w
ith G
Ps a
nd p
atie
nts,
revi
ew a
nd u
pdat
e as
signm
ents
on
a re
gula
r bas
is.
3b.
Asse
ss p
ract
ice
appo
intm
ent s
uppl
y an
d de
man
d, a
nd
bala
nce
GP
to p
atie
nt ra
tio a
ccor
ding
ly.
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
9.
Patie
nts
…ar
e no
t lin
ked
to a
prim
ary
GP
and
care
te
am.
…ar
e lin
ked
to a
prim
ary
GP
and
care
te
am b
ut n
ot ro
utin
ely
used
by
the
prac
tice
for a
dmin
istra
tive
or o
ther
pu
rpos
es.
…ar
e lin
ked
to a
prim
ary
GP
and
care
te
am a
nd ro
utin
ely
used
by
the
prac
tice
mai
nly
for s
ched
ulin
g pu
rpos
es.
…ar
e lin
ked
to a
prim
ary
GP
and
care
te
am a
nd ro
utin
ely
used
for s
ched
ulin
g pu
rpos
es a
nd m
onito
red
for G
P to
pa
tient
ratio
.
10.
Prac
tice
data
…ar
e no
t ava
ilabl
e to
ass
ess o
r man
age
care
for p
ract
ice
popu
latio
ns.
…ar
e av
aila
ble
to a
sses
s and
man
age
care
for p
ract
ice
popu
latio
ns, b
ut o
nly
on a
n ad
hoc
bas
is.
…ar
e re
gula
rly a
vaila
ble
to a
sses
s and
m
anag
e ca
re fo
r pra
ctic
e po
pula
tions
, bu
t onl
y fo
r a li
mite
d nu
mbe
r of
dise
ases
and
risk
stat
es.
…ar
e re
gula
rly a
vaila
ble
to a
sses
s and
m
anag
e ca
re fo
r pra
ctic
e po
pula
tions
, ac
ross
a c
ompr
ehen
sive
set o
f dise
ases
an
d ris
k st
ates
.
11.
Patie
nt re
cord
s…
are
not a
vaila
ble
to c
are
team
s for
pre
-vi
sit p
lann
ing
or p
atie
nt o
utre
ach.
…ar
e av
aila
ble
to c
are
team
s but
are
not
ro
utin
ely
used
for p
re-v
isit p
lann
ing
or
patie
nt o
utre
ach.
…ar
e av
aila
ble
to c
are
team
s and
ro
utin
ely
used
for p
re-v
isit p
lann
ing
or
patie
nt o
utre
ach,
but
onl
y fo
r a li
mite
d nu
mbe
r of d
iseas
es a
nd ri
sk st
ates
.
…ar
e av
aila
ble
to c
are
team
s and
ro
utin
ely
used
for p
re-v
isit p
lann
ing
and
patie
nt o
utre
ach,
acr
oss a
co
mpr
ehen
sive
set o
f dise
ases
and
risk
st
ates
.
12.
Repo
rts o
n ca
re p
roce
sses
or
out
com
es o
f ca
re
…ar
e no
t rou
tinel
y av
aila
ble
to c
are
team
s.…
are
rout
inel
y pr
ovid
ed a
s fee
dbac
k to
ca
re te
ams b
ut n
ot re
port
ed e
xter
nally
.…
are
rout
inel
y pr
ovid
ed a
s fee
dbac
k to
car
e te
ams,
and
repo
rted
ext
erna
lly
(e.g
. to
patie
nts,
othe
r tea
ms,
or e
xter
nal
agen
cies
) but
with
team
iden
titie
s m
aske
d.
…ar
e ro
utin
ely
prov
ided
as f
eedb
ack
to
care
team
s, an
d tr
ansp
aren
tly re
port
ed
exte
rnal
ly to
pat
ient
s, ot
her t
eam
s, an
d ex
tern
al a
genc
ies.
3c.
Use
pra
ctic
e da
ta to
pro
activ
ely
cont
act,
educ
ate,
and
trac
k pa
tient
s by
dise
ase
stat
us, r
isk st
atus
, sel
f-man
agem
ent
stat
us, c
omm
unity
and
fam
ily n
eed.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
8
PCM
H-A
Par
t 4: C
ontin
uous
and
team
-bas
ed h
ealin
g re
latio
nshi
ps
4a.
Esta
blish
and
pro
vide
pra
ctic
e su
ppor
t for
car
e de
liver
y te
ams a
ccou
ntab
le fo
r the
pat
ient
pop
ulat
ion.
4b.
Link
pat
ient
s to
a pr
imar
y G
P an
d ca
re te
am so
bot
h pa
tient
s an
d th
e pr
imar
y G
P/ca
re te
am re
cogn
ise e
ach
othe
r as
part
ners
in c
are.
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
13.
Patie
nts a
re
enco
urag
ed
to se
e th
eir
prim
ary
GP
and
care
team
…on
ly a
t the
pat
ient
’s re
ques
t.…
by th
e ca
re te
am, b
ut is
not
a p
riorit
y in
app
oint
men
t sch
edul
ing.
…by
the
care
team
and
is a
prio
rity
in
appo
intm
ent s
ched
ulin
g, b
ut p
atie
nts
com
mon
ly se
e ot
her G
Ps b
ecau
se o
f lim
ited
avai
labi
lity
or o
ther
issu
es.
…by
the
care
team
, is a
prio
rity
in
appo
intm
ent s
ched
ulin
g, a
nd p
atie
nts
usua
lly se
e th
eir o
wn
prim
ary
GP
or c
are
team
.
14.
Non
-GP
care
te
am m
embe
rs…
play
a li
mite
d ro
le in
pro
vidi
ng c
linic
al
care
.…
are
prim
arily
task
ed w
ith m
anag
ing
patie
nt fl
ow a
nd tr
iage
.…
prov
ide
som
e cl
inic
al se
rvic
es su
ch
as a
sses
smen
t or s
elf-m
anag
emen
t su
ppor
t.
…pe
rfor
m k
ey c
linic
al se
rvic
e ro
les t
hat
mat
ch th
eir a
bilit
ies a
nd c
rede
ntia
ls.
15.
The
prac
tice
…do
es n
ot h
ave
an o
rgan
ised
appr
oach
to
iden
tify
or m
eet t
he tr
aini
ng n
eeds
fo
r GPs
and
oth
er st
aff.
…ro
utin
ely
asse
sses
trai
ning
ne
eds a
nd e
nsur
es th
at st
aff a
re
appr
opria
tely
trai
ned
for t
heir
role
s and
re
spon
sibili
ties.
…ro
utin
ely
asse
sses
trai
ning
nee
ds,
ensu
res t
hat s
taff
are
appr
opria
tely
tr
aine
d fo
r the
ir ro
les a
nd
resp
onsib
ilitie
s, an
d pr
ovid
es so
me
cros
s-tr
aini
ng to
per
mit
staffi
ng
flexi
bilit
y.
…ro
utin
ely
asse
sses
trai
ning
nee
ds,
ensu
res t
hat s
taff
are
appr
opria
tely
tr
aine
d fo
r the
ir ro
les a
nd
resp
onsib
ilitie
s, an
d pr
ovid
es c
ross
-tr
aini
ng to
ens
ure
that
pat
ient
nee
ds a
re
cons
isten
tly m
et.
4c.
Ensu
re th
at p
atie
nts a
re a
ble
to se
e th
eir p
rimar
y G
P or
car
e te
am w
hene
ver p
ossib
le.
4d.
Defi
ne ro
les a
nd d
istrib
ute
task
s am
ong
care
team
mem
bers
to
refle
ct th
e sk
ills,
abili
ties,
and
cred
entia
ls of
team
m
embe
rs.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
9
PCM
H-A
Par
t 5: O
rgan
ised,
evi
denc
e-ba
sed
care
5a.
Use
pla
nned
car
e ac
cord
ing
to p
atie
nt n
eed.
5b.
Iden
tify
high
-risk
pat
ient
s and
ens
ure
they
are
rece
ivin
g ap
prop
riate
and
coo
rdin
ated
car
e se
rvic
es.
Part
5 c
ontin
ued
on n
ext p
age.
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
16.
Com
preh
en-
sive,
gui
de-
line-
base
d in
form
atio
n on
pr
even
tion
or
chro
nic
illne
ss
trea
tmen
t
…is
not r
eadi
ly a
vaila
ble
in p
ract
ice.
…is
avai
labl
e bu
t doe
s not
influ
ence
car
e.…
is av
aila
ble
to th
e ca
re te
am a
nd is
in
tegr
ated
into
car
e pr
otoc
ols a
nd/o
r re
min
ders
.
…gu
ides
the
crea
tion
of ta
ilore
d,
indi
vidu
al-le
vel d
ata
that
is a
vaila
ble
at
the
time
of th
e vi
sit.
17.
Visit
s…
larg
ely
focu
s on
acut
e pr
oble
ms o
f pa
tient
s.…
are
orga
nise
d ar
ound
acu
te p
robl
ems
but w
ith a
tten
tion
to o
ngoi
ng il
lnes
s and
pr
even
tion
need
s if t
ime
perm
its.
…ar
e or
gani
sed
arou
nd a
cute
pro
blem
s bu
t with
att
entio
n to
ong
oing
illn
ess a
nd
prev
entio
n ne
eds i
f tim
e pe
rmits
. The
pr
actic
e al
so u
ses P
EN C
AT re
port
s to
proa
ctiv
ely
call
grou
ps o
f pat
ient
s in
for
plan
ned
care
visi
ts.
…ar
e or
gani
sed
to a
ddre
ss b
oth
acut
e an
d pl
anne
d ca
re n
eeds
. Tai
lore
d gu
idel
ine-
base
d in
form
atio
n is
used
in
team
mee
tings
to e
nsur
e al
l out
stan
ding
pa
tient
nee
ds a
re m
et a
t eac
h en
coun
ter.
5c.
Use
poi
nt-o
f-car
e re
min
ders
bas
ed o
n cl
inic
al g
uide
lines
.
5d.
Enab
le p
lann
ed in
tera
ctio
ns w
ith p
atie
nts b
y m
akin
g up
-to-
date
info
rmat
ion
avai
labl
e to
GPs
and
the
care
team
at t
he
time
of th
e vi
sit.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
10
5a.
Use
pla
nned
car
e ac
cord
ing
to p
atie
nt n
eed.
5b.
Iden
tify
high
-risk
pat
ient
s and
ens
ure
they
are
rece
ivin
g ap
prop
riate
and
coo
rdin
ated
car
e se
rvic
es.
5c.
Use
poi
nt-o
f-car
e re
min
ders
bas
ed o
n cl
inic
al g
uide
lines
.
5d.
Enab
le p
lann
ed in
tera
ctio
ns w
ith p
atie
nts b
y m
akin
g up
-to-
date
info
rmat
ion
avai
labl
e to
GPs
and
the
care
team
at t
he
time
of th
e vi
sit.
PCM
H-A
Par
t 5: O
rgan
ised,
evi
denc
e-ba
sed
care
(con
tinue
d)
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
18.
Care
pla
ns…
are
not r
outin
ely
deve
lope
d or
re
cord
ed.
…ar
e de
velo
ped
and
reco
rded
but
refle
ct
GPs
’ prio
ritie
s onl
y.…
are
deve
lope
d co
llabo
rativ
ely
with
pa
tient
s and
fam
ilies
and
incl
ude
self-
man
agem
ent a
nd c
linic
al g
oals,
but
they
ar
e no
t rou
tinel
y re
cord
ed o
r use
d to
gu
ide
subs
eque
nt c
are.
…ar
e de
velo
ped
colla
bora
tivel
y,
incl
ude
self-
man
agem
ent a
nd c
linic
al
man
agem
ent g
oals,
are
rout
inel
y re
cord
ed, a
nd g
uide
car
e at
eac
h su
bseq
uent
app
oint
men
t.
19.
Coor
dina
ted
care
m
anag
emen
t se
rvic
es fo
r hi
gh-r
isk
patie
nts
…ar
e no
t ava
ilabl
e.…
are
prov
ided
by
exte
rnal
car
e co
ordi
nato
rs w
ith li
mite
d co
nnec
tion
to
prac
tice.
…ar
e pr
ovid
ed b
y ex
tern
al c
are
coor
dina
tors
who
regu
larly
co
mm
unic
ate
with
the
care
team
.
…ar
e sy
stem
atic
ally
pro
vide
d by
the
care
co
ordi
nato
rs fu
nctio
ning
as a
mem
ber
of th
e ca
re te
am, r
egar
dles
s of l
ocat
ion.
20.
Men
tal h
ealth
, al
coho
l abu
se
and
beha
viou
r ch
ange
ou
tcom
es
(suc
h as
im
prov
emen
t in
dep
ress
ion
sym
ptom
s)
…ar
e no
t mea
sure
d.…
are
mea
sure
d bu
t not
trac
ked.
…ar
e m
easu
red
and
trac
ked
on a
n in
divi
dual
pat
ient
-leve
l.…
are
mea
sure
d an
d tr
acke
d on
a
popu
latio
n-le
vel f
or th
e en
tire
prac
tice
with
regu
lar r
evie
w a
nd q
ualit
y im
prov
emen
t effo
rts e
mpl
oyed
to
optim
ise o
utco
mes
.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
11
6a.
Resp
ect p
atie
nt a
nd fa
mily
val
ues a
nd e
xpre
ssed
nee
ds.
6b.
Enco
urag
e pa
tient
s to
expa
nd th
eir r
ole
in d
ecisi
on-m
akin
g,
heal
th-re
late
d be
havi
ours
, and
self-
man
agem
ent.
6c.
Com
mun
icat
e w
ith th
eir p
atie
nts i
n a
cultu
rally
app
ropr
iate
m
anne
r, in
a la
ngua
ge a
nd a
t a le
vel t
hat t
he p
atie
nt
unde
rsta
nds.
6d.
Prov
ide
self-
man
agem
ent s
uppo
rt a
t eve
ry v
isit t
hrou
gh g
oal
sett
ing
and
actio
n pl
anni
ng.
6e.
Obt
ain
feed
back
from
pat
ient
s/fa
mily
abo
ut th
eir h
ealth
care
ex
perie
nce
and
use
this
info
rmat
ion
for q
ualit
y im
prov
emen
t.
PCM
H-A
Par
t 6: P
atie
nt-c
entr
ed in
tera
ctio
ns
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
21.
Asse
ssin
g pa
tient
an
d fa
mily
va
lues
and
pr
efer
ence
s
…is
not d
one.
…is
done
, but
not
use
d in
pla
nnin
g an
d or
gani
sing
care
.…
is do
ne a
nd G
Ps in
corp
orat
e it
in
plan
ning
and
org
anisi
ng c
are
on a
n ad
ho
c ba
sis.
…is
syst
emat
ical
ly d
one
and
inco
rpor
ated
in p
lann
ing
and
orga
nisin
g ca
re.
22.
Invo
lvin
g pa
tient
s in
deci
sion-
mak
ing
and
care
…is
not a
prio
rity.
…is
acco
mpl
ished
by
prov
ision
of p
atie
nt
educ
atio
n m
ater
ials
or re
ferr
als t
o cl
asse
s.
…is
supp
orte
d an
d do
cum
ente
d by
car
e.…
is sy
stem
atic
ally
supp
orte
d by
car
e te
ams t
rain
ed in
dec
ision
-mak
ing
tech
niqu
es.
23.
Patie
nt
com
preh
ensio
n of
ver
bal
and
writ
ten
mat
eria
ls
...is n
ot a
sses
sed.
…is
asse
ssed
and
acc
ompl
ished
by
ensu
ring
that
mat
eria
ls ar
e at
a le
vel a
nd
lang
uage
that
pat
ient
s und
erst
and.
…is
asse
ssed
and
acc
ompl
ished
by
hirin
g m
ulti-
lingu
al st
aff, a
nd e
nsur
ing
that
bo
th m
ater
ials
and
com
mun
icat
ions
are
at
a le
vel a
nd la
ngua
ge th
at p
atie
nts
unde
rsta
nd.
…is
supp
orte
d at
a p
ract
ice
leve
l by
tran
slatio
n se
rvic
es, h
iring
mul
ti-lin
gual
st
aff, a
nd tr
aini
ng st
aff in
hea
lth li
tera
cy
and
com
mun
icat
ion
tech
niqu
es (s
uch
as
clos
ing
the
loop
), en
surin
g th
at p
atie
nts
know
wha
t to
do to
man
age
cond
ition
s at
hom
e.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
Part
6 c
ontin
ued
on n
ext p
age.
12
6a.
Resp
ect p
atie
nt a
nd fa
mily
val
ues a
nd e
xpre
ssed
nee
ds.
6b.
Enco
urag
e pa
tient
s to
expa
nd th
eir r
ole
in d
ecisi
on-m
akin
g,
heal
th-re
late
d be
havi
ours
, and
self-
man
agem
ent.
6c.
Com
mun
icat
e w
ith th
eir p
atie
nts i
n a
cultu
rally
app
ropr
iate
m
anne
r, in
a la
ngua
ge a
nd a
t a le
vel t
hat t
he p
atie
nt
unde
rsta
nds.
6d.
Prov
ide
self-
man
agem
ent s
uppo
rt a
t eve
ry v
isit t
hrou
gh g
oal
sett
ing
and
actio
n pl
anni
ng.
6e.
Obt
ain
feed
back
from
pat
ient
s/fa
mily
abo
ut th
eir h
ealth
care
ex
perie
nce
and
use
this
info
rmat
ion
for q
ualit
y im
prov
emen
t.
PCM
H-A
Par
t 6: P
atie
nt-c
entr
ed in
tera
ctio
ns (c
ontin
ued)
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
24.
Self-
man
agem
ent
supp
ort
…is
limite
d to
the
dist
ribut
ion
of
info
rmat
ion
(e.g
. pam
phle
ts, b
ookl
ets)
.…
is ac
com
plish
ed b
y re
ferr
al to
self-
man
agem
ent c
lass
es o
r edu
cato
rs.
…is
prov
ided
by
goal
sett
ing
and
actio
n pl
anni
ng w
ith m
embe
rs o
f the
car
e te
am.
…is
prov
ided
by
mem
bers
of t
he c
are
team
trai
ned
in p
atie
nt e
mpo
wer
men
t an
d pr
oble
m-s
olvi
ng m
etho
dolo
gies
.
25.
The
prin
cipl
es
of p
atie
nt-
cent
red
care
…ar
e in
clud
ed in
the
prac
tice’s
visi
on
and
miss
ion
stat
emen
t.…
are
a ke
y pr
actic
e pr
iorit
y an
d in
clud
ed
in tr
aini
ng a
nd o
rient
atio
n.…
are
expl
icit
in jo
b de
scrip
tions
and
pe
rfor
man
ce m
etric
s for
all
staff
.…
are
cons
isten
tly u
sed
to g
uide
pr
actic
e ch
ange
s and
mea
sure
syst
em
perf
orm
ance
as w
ell a
s car
e in
tera
ctio
ns
at th
e pr
actic
e le
vel.
26.
Mea
sure
men
t of
pat
ient
-ce
ntre
d in
tera
ctio
ns
…is
not d
one
or is
acc
ompl
ished
usin
g a
surv
ey a
dmin
ister
ed sp
orad
ical
ly a
t the
pr
actic
e le
vel.
…is
acco
mpl
ished
thro
ugh
patie
nt
repr
esen
tatio
n on
boa
rds a
nd re
gula
rly
solic
iting
pat
ient
inpu
t thr
ough
surv
eys.
…is
acco
mpl
ished
by
gett
ing
frequ
ent
inpu
t fro
m p
atie
nts a
nd fa
mili
es u
sing
a va
riety
of m
etho
ds su
ch a
s poi
nt-o
f-ca
re su
rvey
s, fo
cus g
roup
s, an
d on
goin
g pa
tient
adv
isory
gro
ups.
…is
acco
mpl
ished
by
gett
ing
frequ
ent
and
actio
nabl
e in
put f
rom
pat
ient
s and
fa
mili
es o
n al
l car
e de
liver
y iss
ues,
and
inco
rpor
atin
g th
eir f
eedb
ack
in q
ualit
y im
prov
emen
t act
iviti
es.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
13
PCM
H-A
Par
t 7: E
nhan
ced
acce
ss
7a.
Prom
ote
and
expa
nd a
cces
s by
ensu
ring
that
est
ablis
hed
patie
nts h
ave
cont
inuo
us a
cces
s to
care
by
phon
e or
in-
pers
on v
isits
and
afte
r hou
rs.
7b.
Prov
ide
appo
intm
ent o
ptio
ns th
at a
re p
atie
nt- a
nd fa
mily
-ce
ntre
d an
d ac
cess
ible
to a
ll pa
tient
s.
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
27.
Appo
intm
ent
syst
ems
…ar
e lim
ited
to a
sing
le o
ffice
visi
t typ
e.…
prov
ide
som
e fle
xibi
lity
in sc
hedu
ling
diffe
rent
visi
t len
gths
.…
prov
ide
flexi
bilit
y an
d in
clud
e ca
paci
ty
for s
ame
day
visit
s.…
are
flexi
ble
and
can
acco
mm
odat
e cu
stom
ised
visit
leng
ths,
sam
e da
y vi
sits,
sche
dule
d fo
llow
-up,
and
mul
tiple
pr
imar
y G
P vi
sits.
28.
Cont
actin
g th
e ca
re te
am
durin
g re
gula
r bu
sines
s hou
rs
…is
diffi
cult.
…re
lies o
n th
e pr
actic
e’s a
bilit
y to
re
spon
d to
tele
phon
e m
essa
ges.
…is
acco
mpl
ished
by
staff
resp
ondi
ng b
y te
leph
one
with
in th
e sa
me
day.
…is
acco
mpl
ished
by
prov
idin
g a
patie
nt
a ch
oice
of i
nter
actio
ns, u
tilisi
ng sy
stem
s w
hich
are
mon
itore
d fo
r tim
elin
ess.
29.
Afte
r-hou
rs
acce
ss...i
s not
ava
ilabl
e or
lim
ited
to a
n an
swer
ing
mac
hine
.…
is av
aila
ble
from
an
afte
r hou
rs se
rvic
e w
ithou
t a st
anda
rdise
d co
mm
unic
atio
n pr
otoc
ol b
ack
to th
e pr
actic
e fo
r urg
ent
prob
lem
s.
…is
prov
ided
by
an a
fter h
ours
serv
ice
that
shar
es n
eces
sary
pat
ient
dat
a an
d pr
ovid
es a
sum
mar
y to
the
prac
tice.
…is
avai
labl
e vi
a th
e pa
tient
’s ch
oice
of
tele
phon
e or
in-p
erso
n di
rect
ly fr
om
the
care
team
or a
n af
ter h
ours
serv
ice
clos
ely
in c
onta
ct w
ith th
e te
am a
nd
patie
nt in
form
atio
n.
30.
A pa
tient
’s ou
t-of
-poc
ket
expe
nses
…ar
e th
e re
spon
sibili
ty o
f the
pat
ient
to
reso
lve.
…ar
e ad
dres
sed
by th
e pr
actic
e’s
adm
inist
ratio
n te
am.
…ar
e di
scus
sed
with
the
patie
nt p
rior t
o or
dur
ing
the
visit
.…
are
view
ed a
s a sh
ared
resp
onsib
ility
fo
r the
pat
ient
and
an
assig
ned
mem
ber
of th
e pr
actic
e to
reso
lve
toge
ther
.
7c.
Hel
p pa
tient
s und
erst
and
any
out o
f poc
ket e
xpen
ses t
hat
may
be
incu
rred
.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
14
8a.
Link
pat
ient
s with
com
mun
ity re
sour
ces t
o fa
cilit
ate
refe
rral
s an
d re
spon
d to
soci
al se
rvic
e ne
eds.
8b.
Inte
grat
e be
havi
oura
l hea
lth a
nd sp
ecia
lty c
are
into
car
e de
liver
y th
roug
h co
-loca
tion
or re
ferr
al p
roto
cols.
8c.
Trac
k an
d su
ppor
t pat
ient
s whe
n th
ey o
btai
n se
rvic
es o
utsid
e th
e pr
actic
e.
8d.
Follo
w-u
p w
ith p
atie
nts w
ithin
a fe
w d
ays o
f an
emer
genc
y ro
om v
isit o
r hos
pita
l disc
harg
e.
8e.
Com
mun
icat
e te
st re
sults
and
car
e pl
ans t
o pa
tient
s/fa
mili
es.
PCM
H-A
Par
t 8: C
are
coor
dina
tion
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
31.
Med
ical
and
su
rgic
al
spec
ialty
se
rvic
es
…ar
e di
fficu
lt to
obt
ain
relia
bly.
…ar
e av
aila
ble
from
com
mun
ity
spec
ialis
ts b
ut a
re n
eith
er ti
mel
y no
r co
nven
ient
.
…ar
e av
aila
ble
from
com
mun
ity
spec
ialis
ts a
nd a
re g
ener
ally
tim
ely
and
conv
enie
nt.
…ar
e re
adily
ava
ilabl
e fro
m sp
ecia
lists
w
ho a
re m
embe
rs o
f the
car
e te
am
or w
ho w
ork
in a
pra
ctic
e w
ith w
hich
th
e pr
actic
e ha
s a re
ferr
al p
roto
col o
r ag
reem
ent.
32.
Men
tal h
ealth
se
rvic
es…
are
diffi
cult
to o
btai
n re
liabl
y.…
are
avai
labl
e fro
m m
enta
l hea
lth
spec
ialis
ts b
ut a
re n
eith
er ti
mel
y no
r co
nven
ient
.
…ar
e av
aila
ble
from
com
mun
ity
spec
ialis
ts a
nd a
re g
ener
ally
tim
ely
and
conv
enie
nt.
…ar
e re
adily
ava
ilabl
e fro
m m
enta
l hea
lth
spec
ialis
ts w
ho a
re m
embe
rs o
f the
ca
re te
am o
r who
wor
k in
a c
omm
unity
w
ith w
hich
the
prac
tice
has a
refe
rral
pr
otoc
ol o
r agr
eem
ent.
33.
Patie
nts
in n
eed
of
spec
ialty
car
e,
hosp
ital c
are,
or
supp
ortiv
e co
mm
unity
- ba
sed
reso
urce
s
…ca
nnot
relia
bly
obta
in n
eede
d re
ferr
als
to p
artn
ers w
ith w
hom
the
prac
tice
has
a re
latio
nshi
p.
…ob
tain
nee
ded
refe
rral
s to
part
ners
w
ith w
hom
the
prac
tice
has a
re
latio
nshi
p.
…ob
tain
nee
ded
refe
rral
s to
part
ners
w
ith w
hom
the
prac
tice
has a
re
latio
nshi
p an
d re
leva
nt in
form
atio
n is
com
mun
icat
ed in
adv
ance
.
…ob
tain
nee
ded
refe
rral
s to
part
ners
w
ith w
hom
the
prac
tice
has a
re
latio
nshi
p, re
leva
nt in
form
atio
n is
com
mun
icat
ed in
adv
ance
, and
tim
ely
follo
w-u
p af
ter t
he v
isit o
ccur
s.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
Part
8 c
ontin
ued
on n
ext p
age.
15
8a.
Link
pat
ient
s with
com
mun
ity re
sour
ces t
o fa
cilit
ate
refe
rral
s an
d re
spon
d to
soci
al se
rvic
e ne
eds.
8b.
Inte
grat
e be
havi
oura
l hea
lth a
nd sp
ecia
lty c
are
into
car
e de
liver
y th
roug
h co
-loca
tion
or re
ferr
al p
roto
cols.
8c.
Trac
k an
d su
ppor
t pat
ient
s whe
n th
ey o
btai
n se
rvic
es o
utsid
e th
e pr
actic
e.
8d.
Follo
w-u
p w
ith p
atie
nts w
ithin
a fe
w d
ays o
f an
emer
genc
y ro
om v
isit o
r hos
pita
l disc
harg
e.
8e.
Com
mun
icat
e te
st re
sults
and
car
e pl
ans t
o pa
tient
s/fa
mili
es.
PCM
H-A
Par
t 8: C
are
coor
dina
tion
(con
tinue
d)
Item
sLe
vel D
Leve
l CLe
vel B
Leve
l A
34.
Follo
w-u
p by
th
e pr
actic
e an
d ca
re te
am
with
pat
ient
s se
en in
the
Emer
genc
y D
epar
tmen
t (E
D) o
r ho
spita
l
...gen
eral
ly d
oes n
ot o
ccur
bec
ause
th
e in
form
atio
n is
not a
vaila
ble
to th
e pr
imar
y ca
re te
am.
…oc
curs
onl
y if
the
ED o
r hos
pita
l ale
rts
the
prim
ary
care
pra
ctic
e.…
occu
rs b
ecau
se p
ract
ice
mak
es
proa
ctiv
e eff
orts
to id
entif
y pa
tient
s.…
is do
ne ro
utin
ely
beca
use
the
prac
tice
has a
rran
gem
ents
in p
lace
with
the
ED
and
hosp
ital t
o bo
th tr
ack
thes
e pa
tient
s an
d en
sure
that
follo
w-u
p is
com
plet
ed
with
in a
few
day
s.
35.
Link
ing
patie
nts t
o su
ppor
tive
com
mun
ity-
base
d re
sour
ces
…is
not d
one
syst
emat
ical
ly.
…is
limite
d to
pro
vidi
ng p
atie
nts a
list
of
iden
tified
com
mun
ity re
sour
ces i
n an
ac
cess
ible
form
at.
…is
acco
mpl
ished
thro
ugh
a de
signa
ted
staff
per
son
or re
sour
ce re
spon
sible
for
conn
ectin
g pa
tient
s with
com
mun
ity
reso
urce
s.
…is
acco
mpl
ished
thro
ugh
activ
e co
ordi
natio
n be
twee
n th
e he
alth
sy
stem
, com
mun
ity se
rvic
e ag
enci
es
and
patie
nts a
nd a
ccom
plish
ed b
y a
desig
nate
d st
aff p
erso
n.
36.
Test
resu
lts a
nd
care
pla
ns…
are
not c
omm
unic
ated
to p
atie
nts.
…ar
e co
mm
unic
ated
to p
atie
nts b
ased
on
an
ad h
oc a
ppro
ach.
…ar
e sy
stem
atic
ally
com
mun
icat
ed to
pa
tient
s in
a w
ay th
at is
con
veni
ent t
o th
e pr
actic
e.
…ar
e sy
stem
atic
ally
com
mun
icat
ed to
pa
tient
s in
a va
riety
of w
ays t
hat a
re
conv
enie
nt to
pat
ient
s.
Enga
ged
lead
ersh
ip
1
Dat
a-dr
iven
im
prov
emen
t
2Patie
nt-t
eam
pa
rtne
rshi
p
5
Patie
nt
empa
nelm
ent
3
Popu
latio
n m
anag
emen
t
6
Prom
pt
acce
ssto
car
e
8
Team
-bas
ed
care
4
Cont
inui
tyof
car
e
7Com
preh
ensi
vene
ss
and
care
co
ordi
natio
n
9
Qua
lity
gene
ral
prac
tice
of
the
futu
re
10
12
34
56
78
910
1112
12
34
56
78
910
1112
12
34
56
78
910
1112
16
Western NSW Primary Health Network (WNSW PHN) acknowledges this document has been adapted for use in Australia by Northern Queensland Primary Health Network (NQPHN) with permission from the following source:
Safety Net Medical Home Initiative
The Patient-Centred Medical Home Assessment Version 4.0
The MacColl Center for Health Care Innovation at Group Health Research Institute and Qualis Health; Seattle, WA. September 2014.
Australian version development by NQPHN, email: [email protected]
Safety Net Medical Home Initiative
This is a product of the Safety Net Medical Home Initiative, which was supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers, or staff. The Initiative also received support from the Colorado Health Foundation, Jewish Healthcare Foundation, Northwest Health Foundation, The Boston Foundation, Blue Cross Blue Shield of Massachusetts Foundation, Partners Community Benefit Fund, Blue Cross of Idaho, and the Beth Israel Deaconess Medical Center. For more information about The Commonwealth Fund, refer to www.cmwf.org
The objective of the Safety Net Medical Home Initiative was to develop and demonstrate a replicable and sustainable implementation model to transform primary care safety net practices into patient-centred medical homes with benchmark performance in quality, efficiency, and patient experience. The Initiative was administered by Qualis Health and conducted in partnership with the MacColl Center for Health Care Innovation at the Group Health Research Institute. Five regions were selected for participation (Colorado, Idaho, Massachusetts, Oregon, and Pittsburgh), representing 65 safety net practices across the U.S.
For more information about the Safety Net Medical Home Initiative, refer to www.safetynetmedicalhome.org.
17
Patient Centred Medical HomeSelf-assessment Tool
