MCN ToolBox Entries

Much of the medical home model is predicated on a relatively stable population that can access regular care at a single network of providers.  So how can this model effectively transfer to a mobile population?  This crosswalk is meant to assist centers to incorporate the needs of migrating patients into their PCMH. Each of the six standards are listed with the factors required for NCQA recognition. Recommendations for addressing the factors in migrating patients are included, along with resources available through MCN. Meaningful Use and Core Measure content is noted as it is also present.

Clinicians can use this form to collect information from patients about their prior use of non-traditional or alternative care providers and medications.

Health centers can also adapt the form and/or incorporate into their EHR.

PCMH Standard 2 Element B: Clinical Data, Factor 9: List of prescription medications with date of update for 80% of patients.

PCMH Standard 3 Element D: Medication Management, Factor 3: Provides information about new prescriptions to more than 80% of patients.

PCMH Standard 5 Element B: Referral Tracking and Follow-up, Factor 5: Asks patients about self-referrals and requests specialist reports.

Family Psychosocial Screening also assesses a number of other risk factors for developmental and behavior problems. These include frequent household moves, single parenting, three or more children in the home, less than a high school education, and unemployment. Four or more such risk factors including mental health problems and an authoritarian parenting style (observed when parents use commands excessively or are negative and less than responsive to child initiated interests) is associated with a substantial drop in children's intelligence and subsequent school achievement . In such cases, children should also be referred for early stimulation programs such as Head Start or a quality day care or preschool program. 

PCMH Standard 2, Element C: Comprehensive Health Assessment, Factor 2: Practice conducts and documents a health assessment including family, social, cultural characteristics.