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Table 2 Intervention ‘high-value’ elements

From: Study protocol: transforming outcomes for patients through medical home evaluation and redesign: a cluster randomized controlled trial to test high value elements for patient-centered medical homes versus quality improvement

Element Description Specific example metric* Alignment with reform
Identification of at-risk populations and care management Care plan utilization Tier 3—PCMH provides care plans to >50% of high-risk patients. Moderate
Advance directive utilization Tier 3—The PCMH offers advance directives to at least 50% of patients over 65.
Based on need Care management outreach Tier 2—PCMH’s care coordination outreach reaches 50% of high-risk patients.
Patient engagement and proactive goal setting Education and self-management resources Tier 2—More than 10% of all unique patients are provided patient-specific education resources and self-management services. Strong
Reminders Tier 3—PCMH sends appropriate reminders to at least 20% of all eligible patients.
Integrated information and procedures across settings Clinical information exchange Tier 1—PCMH exchanges structured clinical information and tracks critical elements (e.g., hospitalizations). Strong
Utilization monitoring and follow-up Tier 3—PCMH follows up on patient hospitalizations and ED visits 70% of the time (when they have the information).
Population management tools Performance data utilization Tier 1—The PCMH uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency, and patient experience. Strong
Receive and respond to electronic requests Tier 3—The PCMH provides a response to online or electronic queries within two business days.
Improved access After-hours access Tier 1—PCMH offers access to in-person care at least 12 h weekly outside traditional business hours. Strong
Tracking 3rd next available appointments
  1. *Nine metrics are solely applicable to primary care, and eight include primary care and other aspects of the health care system.