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Patient-Centered Medical Home Resources
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The resources on this page are organized by presentationsresource documents (reports, issue briefs, fact sheets, websites), and tools and templates (spreadsheets, modifiable Word documents, job descriptions). If you don't find what you are looking for you can search by keyword using the search field at the top of this page. Please feel free to email any additions to the library you feel would be helpful to others; contact Simmi Isaac at sisaac@mpca.net.

 

Resources

Tools & Templates

Qualis 2014 PCMH NCQA Standards - Assessment Tool and Document Requirements

This easy-to-use tool will help you assess where you stand with respect to the 2014 NCQA PCMH requirements, and is intended for use at the outset of the survey process. Evaluating your starting point will help you to set goals, and to begin to work with and understand the NCQA requirements. Please note: the score you obtain using this tool does not guarantee your receipt of the same score from NCQA since NCQA’s determination of your score for each element depends on the quality of the documentation provided for each element. The Baseline PCMH Self-Assessment Tool contains your summary score, as well as a score for each of the six NCQA PCMH standards. Based on the responses you provide for each of the six standards, the tool will automatically calculate your summary score. This includes the total points you will receive, the number of “must-pass” elements your organization will pass at the 50% level and the level of recognition NCQA is likely to grant your organization.

 

Qualis 2014 PCMH NCQA Renewal Plan

For practices that have achieved Level 2 or Level 3 Recognition under the NCQA PCMH 2011 Standards, NCQA offers a streamlined process to renew Recognition under the NCQA PCMH 2014 Standards through reduced documentation. The purpose of this tool is to assist practices in planning for the Streamlined Renewal process. This tool provides a place for practices to document their current status and action steps for each Element, as appropriate, for planning the Streamlined Renewal Submission.  

NCQA PCMH 2014 Recognition Road Map

Are you uncertain about the type of application that you must submit?  The link above will provide additional information on the differences in the Full Survey, Add-On, Renewal, Streamlined Renewal, and Conversion, and the corresponding eligibility and documentation requirements, including processing time frames and pricing information.

 

 

Presentations & Papers

Archived Presentations, Resources, Tools & Templates

An Overview of the AAAHC Accreditation Standards for Ambulatory Health Care
2015 | PDF | Source: Accreditation Association for Ambulatory Health Care, Inc.
A presentation on AAAHC standards, survey process and review of quality studies.
 

The PCMH 210: Laying the Framework for Patient Centered Care

2014 | Slideshare | Source: Quality First Healthcare Consulting Candace Chitty 

The PCMH 101: Where Do We Start in Patient Centered
2014 | Slideshare | Source: Quality First Healthcare Consulting Candace Chitty 

APCP PCMH Webinar Series
 (to access the individual webinars, click on each title below)

2014 | Source:Coleman Associates

 

Debunking the Insatiable Patient Demand "Access Myth" 

Ever feel like your Health Center is being besieged by patients? Do you feel over-demanded and have to keep saying no to your patients? Laura and Amanda debunk this Access Myth by exploring the reality they see in Health Centers nationwide: there is hidden capacity that isn't being revealed, tapped or discovered. Amanda and Laura show PCA Coaches and Health Center staff where this hidden capacity is lurking by teaching real techniques for removing barriers to seeing patients without having to hire additional staff.

 

Matching Capacity with Demand 

Real strategies from the field for front-line staff to improve the relationship with the patient via no-show reduction efforts, and active management of the patient schedule in real time. These two techniques alone will allow front-line staff more control over the day to ease the chaos of the Health Center day that providers, nurses, and MA staff face. Join Laura and Amanda to learn how to utilize these tactics. This is not just for front-desk staff, MAs can do this and providers will benefit from this as it greatly impacts their patient flow for the day.

 

The Key to an Effective Work Flow between MAs, Providers and Nurses: Working Together by doing the Team Dance

More often than not providers, nurses, and MAs are left to their own devices to discover their team rhythm and a way to cooperate with one another. The strongest personality's way of working tends to prevail, regardless of how efficient this way actually is. Laura and Amanda explore a systematic process for Patient Care Teams to communicate in the back throughout patient visits. Amanda and Laura show PCA coaches and Health Center staff specific communication techniques that just like a dance require fluidity, technical savvy, and cooperation to carry out the clinic day successfully and gracefully!

 

It's all in the Anticipation! Prepare for the Expected 

Does every day feel like you're waiting to get through the exam room door to discover today's surprises? Do you say to yourself, "I wonder what'll catch me by surprise during this visit and derail my day today?" Do you feel under-prepared and always a step behind? Get ready to grab the bull by the horns every morning! Laura and Amanda reveal the structure and detail of a successful true Patient Care Team huddle! Amanda and Laura show show you how, what, where, and when to use a direct communication process as a team so surprises comprise 10% of your day, not 50%!


2013 | PDF | Source: Roger Coleman, MBA & Melissa Stratman, BA, Coleman Associates
Coleman Associates share hard-won lessons learned from Rapid DPIs that every manager, clinician, or team leader can begin applying immediately. They also share performance outcomes of Rapid DPI clinics to demonstrate the huge potential for improvement at almost every Health Center.
Presented at the 2013 MPCA Annual Conference


Aligning Payment with Patient-Centered Care and Value-Based Pay

2013 | PDF | Source: Craig Hostetler, Oregon Primary Care Association
This session describes the health care environment that led to the development of the Oregon Alternative Payment Methodology, why Health Centers are taking the risk, and risks associated with the model that should not be underestimated.
Presented at the 2013 MPCA Annual Conference


Our Road to PCMH Recognition

2013 | PPT | Source: Russ Kolski, RN, Baldwin Family Health Care

 

A Guide to Real-World Evaluations of Primary Care Interventions
2014 | PDF | Source: Agency for Healthcare Research and Quality
This Evaluation Guide provides practical advice for designing real-world evaluations of interventions such as the Patient Centered Medical Home (PCMH) and other models to improve primary care delivery.
 

NCQA PCMH 2014 Renewal Planning Tool

2014 | Excel | Source: Qualis Health

This tool is for practices that have achieved Level 2 or Level 3 Recognition under the NCQA PCMH 2011 Standards, NCQA offers a streamlined process to renew Recognition under the NCQA PCMH 2014 Standards through reduced documentation.

 

PCMH Sustainability Toolkit - Triple Play
2014 | Excel | Source: Primary Care Development Corporation
This tool contains 9 sheets of data entry that encompass three sections: process, performance, and outcomes.

Performance Improvement Questionnaire - Triple Play
2014 | Word | Source: Primary Care Development Corporation

Competing Priorities Worksheet - Triple Play
2014 | Word | Source: Primary Care Development Corporation

The Joint Commission - Triple Play
2014 | Word | Source: Primary Care Development Corporation

TJC_PCMH_Roadmap - Triple Play
2014 | Excel | Source: Primary Care Development Corporation

Model_PCMH_Roadmap - Triple Play
2014 | Excel | Source: Primary Care Development Corporation

Model_PCMH_Sustainability_Roadmap - Triple Play

2014 | Excel | Source: Primary Care Development Corporation

PCDC Questions Game Show - Triple Play
2014 | PPT | Source: Primary Care Development Corporation

The Triple Play - Triple Play
2014 | PPT | Source: Primary Care Development Corporation

CCNC PCMH Resource Center
2013 | Website | Source: Community Care of North Carolina


PCMH Recognition Checklist

2013 | PDF | Source: Community Care of North Carolina


New Hedis Hypertension Performance Measure

2013 | PDF | Source: Baldwin Family Health Care


Priority Health MQIC Hypertension

2013 | PDF | Source: Baldwin Family Health Care
Guidelines for hypertension control.


Blood Pressure Self Management Goals

2013 | PPT | Source: Baldwin Family Health Care
Blood pressure self management tool.


The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

2013 | PDF | Source: Baldwin Family Health Care


Priority Health MQIC Hypertension Guidelines

2013 | PDF | Source: Baldwin Family Health Care
Guidelines for hypertension.


Hypertension Diagnosis and Treatment Recommendations

2013 | PDF | Source: Baldwin Family Health Care


Smoking Cessation Protocol

2013 | Word | Source: Baldwin Family Health Care


Smoking Self Management

2013 | PPT | Source: Baldwin Family Health Care
Smoking self management tool.


Priority Health MQIC Tobacco Control

2013 | PDF | Source: Baldwin Family Health Care
Guidelines for tobacco control.


Tobacco Cessation Algorithm

2013 | PDF | Source: Baldwin Family Health Care
Tobacco cessation algorithm.


Asthma Self Management

2013 | PDF | Source: Baldwin Family Health Care
Patient self management tool.


Priority Health MQIC Asthma Patients Ages 5-11

2013 | PDF | Source: Baldwin Family Health Care
Guidelines for asthma management in patients ranging from 5-11 years old.


Asthma Self Management

2013 | PPT | Source: Baldwin Family Health Care
Asthma self management tool.


Asthma Diagnosis and Management

2013 | PDF | Source: Baldwin Family Health Care


Patient Education Talking Points Asthma

2013 | Word | Source: Baldwin Family Health Care
Education material for patients with asthma.


Priority Health MQIC Asthma

2013 | PDF | Source: Baldwin Family Health Care
Guidelines for asthma management.

 

Lean Activities of PCMH
2013 | Word | Source: Baldwin Family Health Care


Medical Visit

2013 | Excel | Source: Baldwin Family Health Care
Patient visit work flow tool.


NCQA PCMH Requirements Tracking

2013 | Excel | Source: Baldwin Family Health Care
Tracking tool of must pass elements.


PCMH Patient Education Protocol

2013 | Word | Source: Baldwin Family Health Care
NCQA PCMH 4-A template.


Motivational Interviewing

2013 | PDF | Source: Baldwin Family Health Care


Quality Monitors

2013 | Word | Source: Baldwin Family Health Care
Working tool for quality reporting.


Baldwin Family Health Care Goal Comparisons

2013 | Excel | Source Baldwin Family Health Care
Tool for goal comparison.


NCQA Reporting Priorities

2013 | Excel | Source: Baldwin Family Health Care
Tool for reporting for PCMH NCQA recognition.


All Known Clinical Quality Measures

2013 | Excel | Source: Baldwin Family Health Care
Working document of PCMH clinical quality measures.


Baldwin Family Health Care's Sample Brochure

2013 | PDF | Source: Baldwin Family Health Care
Sample brochure of Baldwin Family Health Care.


Open Access Staff Training

2013 | PPT | Source: Baldwin Family Health Care
Baldwin Family Health Care staff training on open access


ADA Standards of Care in Diabetes

2013 | PDF | Source: Baldwin Family Health Care
Published ADA standards of care.


Monitoring Diabetes

2013 | PPT | Source: Baldwin Family Health Care
Patient self management of diabetes.

Patient Education Talking Points Diabetes
2013 | Word | Source: Baldwin Family Health Care
Education material for patients with diabetes.


Timeline to NCQA

2013 | Word | Source: InterCare Community Health Network
Timeline of implementation of standards before submission to National Committee for Quality Assurance.


PCMH Self Assessment

2013 | Word | Source: Arkansas Primary Care Association
A factor-by-factor assessment tool.


 
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