Identifies the predominant conditions and health concerns of the patient population
Characteristics
COORDINATED
Component
Population health oriented
[SYSTEM LEVEL ONLY]
Measure Concept
Identifies and addresses population-level health concerns based on the diversity of the practice and the community
[SYSTEM LEVEL ONLY]
Descriptions
The practice identifies its patients' most prevalent and important conditions and concerns, through analysis of diagnosis codes or problem lists.
Although the general conditions treated in primary care are similar across practices, each medical home has a unique population that influences how the practice organizes their work and resources. Knowing its population's top concerns allows the practice to adopt guidelines, focus decision support and outreach efforts, identify specialties to establish clearer referral relationships and determine what special services to offer (e.g., group sessions, education, counseling) that align with those needs.
Measure or Standard
Standard
Populations
Not specified or not applicable
Level of Measure
Practice/Health Center
Data Source
Evidence of implementation
Measure Identification
NCQA 2017 PCMH standards
Developer/Steward
National Committee for Quality Assurance (NCQA)
Stage of Development/Use
Accreditation