Table 1

PCMH Domains of Function and Numbers of Capabilities Assessed

No.DomainDescriptionaCapabilities, No.
1Patient-Provider PartnershipPractice has developed and is using PCMH-related communication tools8
2Patient RegistryAn all-payer registry is used to manage established patients in the practice18
3Performance ReportingPerformance reports are generated that allow tracking and comparison of results for the established population of patients in the practice13
4Individual Care ManagementPractice 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 needs15
5Extended AccessPatients 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 PCMH9
6Test Results Tracking & Follow-upPractice 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 results9
7E-prescribingPractice has adopted and uses electronic prescribing and clinical decision support tools to improve the safety, quality, and cost-effectiveness of the prescription process2
8Preventive ServicesPrimary prevention program is in place that focuses on identifying and educating patients about personal health behaviors to reduce their risk of disease and injury8
9Linkage to Community ServicesA comprehensive review of, and linkage to, community resources has been completed8
10Self-Management SupportA 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 behaviors8
11Patient Web PortalA 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 tools12
12Coordination of CareFor 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 place9
13Specialist Referral ProcessProcedures are in place to guide each phase of the specialist referral process9