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Definition of the medical home tiers

Definition of the medical home tiers

Tier 1

Practices will need to achieve all 17 of these requirements to be deemed a Tier 1 medical home:

Continuity

1. The practice holds discussion with patients and presents written information on the role of the medical home that addresses up to eight areas

2. The practice establishes written standards on scheduling each patient with a personal clinician for con-tinuity of care and collects data to show that it meets its continuity standards

Clinical information systems

3. The practice uses an electronic data system that includes searchable data, such as patient demographics, visit dates, and diagnoses (up to 12 specific factors), as well as an electronic or paper-based system to identify clinically important conditions or risk factors among its patient population

Delivery system redesign

4. The practice establishes written standards to support patient access, including policies for scheduling visits and responding to telephone calls and electronic communication (up to nine specific factors)

5. The practice collects data to demonstrate that it meets standards related to appointment scheduling and response times for telephone and electronic communication (up to five specific factors)

6. The practice defines roles for physician and nonphysician staff members and trains employees involved in reminding patients of appointments, executing standing orders, and educating patients and families

7. The practice uses electronic or paper-based tools, including medication lists and other tools such as problem lists or structured templates, for notes or preventive services to organize and document clinical information in the medical record

8. The practice conducts a comprehensive health assessment for all new patients to understand their risks and needs, including past medical history, risk factors, and preferences for advance care planning (up to five specific factors)

9. For three clinically important conditions, the physician and nonphysician staff conduct care management using an integrated care plan to set goals, assess programs, and address barriers (five specific factors)

10. For three clinically important conditions, the physician and nonphysician staff conduct care management planning ahead of the visit to make sure that information is available and the staff is prepared, as well as following up after the visit to make sure that the treatment plan (including medications, tests, and referrals) is implemented

11. The practice identifies appropriate evidence-based guidelines that are used as the basis of care for clinically important conditions

Patient/family engagement

12. The practice supports patient/family self-management through activities such as systematically assessing patient-/family-specific communication barriers and preferences, providing self-monitoring tools or personal health records, and providing a written care plan

13. The practice supports patient/family self-management through providing educational resources and providing/connecting families to self-management resources

14. The practice encourages family involvement in all aspects of patient self-management

Coordination

15. The practice systematically tracks tests and follows up using steps such as making sure that results are available to the clinician, flagging abnormal test results, and following up with the patient/family on abnormal test results (up to four specific factors)

16. The practice coordinates referrals designed as critical through steps such as providing the patient and referring physician with the reason for the consultation and pertinent clinical findings, tracking the status of the referral, obtaining a report back from the practitioner, asking patients about self-referrals, and obtaining reports from the practitioner

17. The practice reviews all medications a patient is taking, including prescriptions, over-the-counter medications, and herbal therapies/supplements

Tier 2

Practices will need to achieve all of the first 19 requirements and three of requirements 20–28 to be considered a Tier 2 medical home:

Continuity

1. The practice holds discussion with patients and presents written information on the role of the medical home that addresses up to eight areas

2. The practice establishes written standards on scheduling each patient with a personal clinician for continuity of care and collects data to show that it meets its continuity standards

Clinical information systems

3. The practice uses an electronic data system that includes searchable data, such as patient demographics, visit dates, and diagnoses (up to 12 specific factors); an electronic or paper-based system to identify clinically important conditions or risk factors among its patient population; and an electronic health record certified by the Certification Commission on Health Information Technology that captures searchable data on clinical information such as blood pressure, lab results, or status of preventive services (up to nine specific areas)

Delivery system redesign

4. The practice establishes written standards to support patient access, including policies for scheduling visits and responding to telephone calls and electronic communication (up to nine specific factors)

5. The practice collects data to demonstrate that it meets standards related to appointment scheduling and response times for telephone and electronic communication (up to five specific factors)

6. The practice denies roles for physician and non-physician staff members and trains employees involved in reminding patients of appointments, executing standing orders, and educating patients and families

7. The practice uses electronic or paper-based tools, including medication lists and other tools such as problem lists or structured templates, for notes or preventive services to organize and document clinical information in the medical record

8. The practice conducts a comprehensive health assessment for all new patients to understand their risks and needs, including past medical history, risk factors, and preferences for advance care planning (up to five specific factors)

9. For three clinically important conditions, the physician and nonphysician staff conduct care management using an integrated care plan to set goals, assess progress, and address barriers (five specific factors)

10. For three clinically important conditions, the physician and nonphysician staff conduct care management planning ahead of the visit to make sure that information is available and the staff is prepared, as well as following up after the visit to make sure that the treatment plan (including medications, tests, and referrals) is implemented

11. The practice identifies appropriate evidence-based guidelines that are used as the basis of care for clinically important conditions

Patient/family engagement

12. The practice supports patient/family self-management through activities such as systematically assessing patient-/family-specific communication barriers and preferences, providing self-monitoring tools or personal health records, and providing a written care plan

13. The practice supports patient/family self-management through providing educational resources and providing/connecting families to self-management resources

14. The practice encourages family involvement in all aspects of patient self-management

Coordination

15. The practice systematically tracks tests and follows up using steps such as making sure that results are available to the clinician, flagging abnormal test results, and following up with the patient/family on all abnormal test results (up to four specific factors)

16. The practice coordinates referrals designed as critical through steps such as providing the patient and referring physician with the reason for the consultation and pertinent clinical findings, tracking the status of the referral, obtaining a report back from the practitioner, asking patients about self-referrals, and obtaining reports from the practitioner

17. The practice reviews all medications a patient is taking, including prescriptions, over-the-counter medications, and herbal therapies/supplements

18. The practice, on its own or in conjunction with an external organization, has a systematic approach for identifying and coordinating care for patients who receive care in inpatient or outpatient facilities or are transitioning to other care (up to six specific factors)

19. The practice reviews posthospitalization medication lists and reconciles with other medications

Clinical information systems

20. The practice uses an electronic system to write prescriptions that can print or send prescriptions elec-tronically; clinicians write prescriptions using electronic prescription reference information at the point of care, including safety alerts that may be generic or specific to the patient (up to eight specific factors); and clinicians engage in cost-efficient prescribing by using a prescription writer that has general automatic alerts for generic drugs or is connected to a payer-specific formulary

21. The practice provides patients/families with access to a Web site that allows electronic communication

22. The practice provides for patient access to personal health information, such as test results or prescription refills, or allows patients to see elements of their medical home and import elements of their medical record into a personal health record

Delivery system redesign

23. The practice measures or receives data on performance, such as clinical processes, clinical outcomes, service data, or patient safety issues, and collects data on patient experience

24. The practice reports performance data to physicians

25. The practice uses performance data to set goals and take action where it identifies a need to improve performance

26. The practice uses electronic information to generate lists of patients and take action to remind patients or clinicians proactively of services needed, such as patients needing clinician review, action or reminders for preventive care, specific tests, or follow-up visits (up to five specific factors)

27. The practice uses a paper-based or electronic system for reminders at the point of care based on guidelines for preventive services, such as screening tests, immunizations, risk assessments, and counseling

28. The practice uses a paper-based or electronic system for reminders at the point of care based on guidelines for chronic care needs

Source

Centers for Medicare & Medicaid Services.