Domain | Definition |
---|---|
1: Patient rostering | Patients are assigned to specific providers and care teams. |
Patient data is routinely used for scheduling purposes and monitored to balance supply and demand. | |
Electronic medical records on individual patients are available to practice teams. | |
Reports on care processes are provided. | |
2: Continuous, team-based healing relationships | Patient sees their own provider or team. |
Non-physician practice team members perform key clinical service roles that match their ability and credentials. | |
Staff is properly trained for roles and responsibilities. | |
3: Patient-centered interactions | Patients are driving their care. |
Patient and family values and preferences are assessed and incorporated in planning and organizing care. | |
Communication techniques are used, such as translation services, to ensure the patient can understand. | |
Self-management support is provided. | |
Patient-centeredness is consistently used to guide organizational changes. | |
Frequent and actionable input from patients and family members is used for quality improvement. | |
4: Engaged leadership | Leaders support continuous learning, review and act upon quality data, and have long-term strategy and funding commitment to explore and implement change. |
Clinical leaders champion and engage clinical teams in improving patient experience of care and clinical outcomes. | |
Hiring and training supports and sustain improvements. | |
Responsibility for quality improvement activities is shared by staff, and time is protected to meet to engage in quality improvement. | |
5: Quality improvement strategy | Electronic health record and other health information technology used to support population management and quality improvement efforts. |
Feedback provided to care teams and staff to improve processes and outcomes. | |
Performance measurement is used and reported back to providers. | |
6: Enhanced access | Appointments are flexible and can accommodate customized visit lengths, same-day visits, and scheduled follow-up. |
Choice of phone, e-mail to contact the practice team during normal hours. | |
After-hours access is available. | |
Enhanced access includes eliminating barriers to care including those related to a patient's ability to pay. | |
7: Care coordination | Care coordinated within practice, creating a care hub, and between the practice and outside services. |
Team reaches out and connects in meaningful ways with other sources of service, and communicates consistently and without delay. | |
8: Organized, evidence-based care | Guideline based care that incorporates preventative and chronic illness needs. |
Visits are organized to address both acute and planned care needs. | |
Case managers are available, and used for high risk patients. | |
Care plans are developed collaboratively, including clinical management. |
PCMH, patient-centered medical home.