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.
