PCMH Domains of Function and Numbers of Capabilities Assessed
| No. | Domain | Descriptiona | Capabilities, No. |
|---|---|---|---|
| 1 | Patient-Provider Partnership | Practice has developed and is using PCMH-related communication tools | 8 |
| 2 | Patient Registry | An all-payer registry is used to manage established patients in the practice | 18 |
| 3 | Performance Reporting | Performance reports are generated that allow tracking and comparison of results for the established population of patients in the practice | 13 |
| 4 | Individual Care Management | Practice has ability to deliver coordinated care management services with an integrated team of multidisciplinary clinicians and a systematic approach is in place to deliver comprehensive care that addresses patients’ full range of health care needs | 15 |
| 5 | Extended Access | Patients have 24-hour access to a clinical decision maker by telephone, and the clinical decision maker has a feedback loop within 24 hours or the next business day to the patient’s PCMH | 9 |
| 6 | Test Results Tracking & Follow-up | Practice has test-tracking process documented and in place that requires tracking and follow-up for all tests and results, with identified time frames for notifying patients of results | 9 |
| 7 | E-prescribing | Practice has adopted and uses electronic prescribing and clinical decision support tools to improve the safety, quality, and cost-effectiveness of the prescription process | 2 |
| 8 | Preventive Services | Primary prevention program is in place that focuses on identifying and educating patients about personal health behaviors to reduce their risk of disease and injury | 8 |
| 9 | Linkage to Community Services | A comprehensive review of, and linkage to, community resources has been completed | 8 |
| 10 | Self-Management Support | A systematic approach is in place to empower the patient to understand their central role in effectively managing their illness, making informed decisions about care, and engaging in healthy behaviors | 8 |
| 11 | Patient Web Portal | A patient Web portal is in use by the practice to allow for electronic communication between patients and physicians, and to provide greater access to medical information and technical tools | 12 |
| 12 | Coordination of Care | For patients with selected chronic conditions, a mechanism is established for being notified of each patient admission and discharge or other type of encounter, and appropriate transition plans are in place | 9 |
| 13 | Specialist Referral Process | Procedures are in place to guide each phase of the specialist referral process | 9 |
PCMH=patient-centered medical home.
Note: The total number of capabilities is 128.
↵a Details provided in Supplemental Appendix 2, available online only at http://annfammed.org/content/11/Suppl_1/S74/suppl/DC1.