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Become a PCMH

Best Practices

Feel good about PCMH

Best practices will guide you on the road to becoming a successful PCMH. Using these benchmarks, we will work together to improve population health and patient engagement, while reducing per-person health care costs.

  • Demonstrate that the concepts of the medical home are understood and actively supported by practice leaders
  • Ensure access to primary care services for attributed members
  • Use registry and EMR for effective population management and productive patient follow-up
  • Schedule new patients for PCP and annual visits for the recommended age and gender-specific preventive services
  • Assign and train care teams to coordinate care for individual team members
  • Actively engage with patients in need of care management, including the development, maintenance, and oversight of care plans
  • Provide self-management education and support to qualified patient populations
  • Connect members to community services
  • Coordinate referrals and test results with specialists and follow up on referrals
  • Initiate ongoing quality improvement activities
  • Create reports to analyze and share practice performance improvements
  • Share data and information with health plan care managers and care coordinators

Questions? Contact a local account rep.