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PCMH 3: Plan and Manage Care

PCMH 3: Plan and Manage Care. Intent of Standard Practice implements evidence-based guidelines High-risk patients identified Care team performs care mgt through pre-visit planning, developing plan and treatment goals. Meaningful Use Alignment Practice implements evidence-based guidelines

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PCMH 3: Plan and Manage Care

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  1. PCMH 3: Plan and Manage Care Intent of Standard • Practice implements evidence-based guidelines • High-risk patients identified • Care team performs care mgt through pre-visit planning, developing plan and treatment goals Meaningful Use Alignment • Practice implements evidence-based guidelines • Practice reviews and reconciles medications with patients • Practice uses e-prescribing systems

  2. PCMH 3: Plan and Manage Care

  3. PCMH 3A: Implement Evidence-Based Guidelines Practice implements guidelines through point of care reminders for patients with: 1. the first important condition (core MU 1) 2. second important condition 3. third condition, related to unhealthy behaviors or mental health or substance use/abuse – CRITICAL: FACTOR

  4. PCMH 3B: Identify High-Risk Patients The practice does the following to identify high-risk patients: • Establishes criteria and a process to identify high-risk or complex patients • Determines the percentage of high-risk patients in the population

  5. Identifying High-Risk Patients • Practice has specific criteria and a process to identify complex or high-risk patients for whole person care planning and management • May be based on: • High resource use, frequent visits, hositalizations • Multiple co-mordbidities, including mental health • Noncompliance to treatemnt/medications • Terminal illness • Impediments to care • Advanced age, with frailty • Multiple risk factors

  6. PCMH 3C: Care Management Care team performs the following for at least 75% of patients from Elements A and B • Conducts pre-visit preparations • Collaborates with patient to develop care plan • Gives patient care plan • Assesses and addresses barriers to treatment goals

  7. PCMH 3C: Care Management 5. Gives patient clinical summary of relevant visits. 6. Identified patients who need more care management support. 7. Follow up with patients who have not kept important appointments.

  8. Documentation 3C, 3D, and 4A • Workbook is all that is required

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