Proactively and routinely identifies populations of patients and reminds them, or their families/caregivers about needed services
Characteristics
COORDINATED
Component
Population health oriented
[SYSTEM LEVEL ONLY]
Measure Concept
Proactively identifies populations of patients and educates them about needed care
[SYSTEM LEVEL ONLY]
Descriptions
Proactively and routinely identifies populations of patients and reminds them, or their families/caregivers about needed services (must report at least three categories):
A. Preventive care services.
B. Immunizations.
C. Chronic or acute care services.
D. Patients not recently seen by the practice.
The practice uses lists or reports to manage the care needs of specific patient populations. Using collected data on patients, the practice addresses a variety of health care needs using evidence-based guidelines, including missing recommended follow-up visits. The practice implements this process at least annually to proactively identify and remind patients, or their families/caregivers, before they are overdue for services.
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