Table 1.

National Committee for Quality Assurance summary of PCMH standards [6]

Standard	Summary
Enhance access and continuity of care	Patient access to routine and urgent care during and after office hours including electronic access; Culturally and linguistically appropriate care is provided; Focus is on team-based care with trained staff; Patients can select a clinician
Identify and manage patient populations	Collection of demographic and clinical data by the practice for population management; Assessment and documentation of patient risk factors by the practice; Identification of practice and point-of-care reminders
Plan and manage care	Medication reconciliation at visits and after hospitalization; Use of e-prescribing; Care management focuses on pre-visit planning and working toward treatment goals; Identification of patients with high-risk care needs such as mental health and substance abuse problems
Provide self-care support and community resources	Assessment and development of patient/family self-care plans; Counseling on healthy behaviors; Provide or arrange mental health and substance abuse treatment
Track and coordinate care	Track, follow up, and coordinate tests and referrals; Follow-up of discharged patients
Measure and improve performance	Use of performance and patient data to continuously improve; Track measures such as hospitalization rates and ER visits; Identify vulnerable patient populations; Demonstrate improved performance as a practice