Change Concepts

• Use planned care according to patient need.
• Use point-of-care reminders based on clinical guidelines.
• Enable planned interactions with patients by making up-to-date information available to providers and the care team at the time of the visit.
  
  

For those interested in the congruence between the Chronic Care Model (CCM) and the PCMH, this change concept is one place where key parts of the CCM are made explicit, especially Delivery System Design and Decision Support.

The goal of this change concept is to make evidence-based care routine. This is accomplished through both planned interactions initiated by the practice, and through point-of-care reminders which help ensure that every interaction is informed by the clinical needs and wishes of the patient.

This means that the availability of up-to-date patient information is key, as is the care team’s ability to review patient data before the visit and communicate via team huddles or other formats to work efficiently as a unit and maximize the value of each interaction.

• Coming Soon