Chapter 25 - Medical Home
Possible Survey Review Items
This list represents some of the items that an AAAHC surveyor may review during an on-site survey.
Chapter 25 - Medical Home
A. Physician/team Relationship with a patient
· Patient can identify
· Information explained
· Listens
· Speaks
· Easy-to-understand instructions
· Knows the patient history
· Spends appropriate time with patient
· Thorough as patient feels necessary
· Informed of delay in appointment
· Addresses principles to prevent illness
· Speaks about lifestyle changes to prevent illness
· Inquiries about patient concerns/worries/stressors
· Inquiries about mental health status
· Provides services within a team framework
· Family included in decisions and treatment
· Treated with cultural sensitivity
B. Continuity of Care
· Visits (50%) with same provider/team
· Consultations ordered documented
· Referrals documented
· Consultations returned documented
· Referrals are disease/procedure specific
· Referral results documented
· Follow-up appointments documented
· After-hours encounters documented
· Missed appointments documented and managed
· Critical referrals/consultations/diagnostics are tracked and follow-up
· Transitions of care planned, coordinated, and documented
· Electronic data management used as a tool for facilitating the standards
C. Comprehensiveness of Care
· Limits of populations served discussed with patients
· Scope of services includes:
o Preventive care
o Wellness care
o Acute illness and injury
o Chronic illness management
o End of life care
· Provide patient education and self management resources
· Knowledge of community resources
· Community service limitations are known
· Referrals are appropriate to the patients’ needs
· Needs of personal caregiver is assessed
· Electronic data management used as a tool for facilitating the standards
D. Accessibility
· Written standards support patient access
· Patients are assessed for their perception of access
· Patients are provided information about 24/7 medical care
· On-call coverage exists
· Electronic data management used as a tool for facilitating the standards
E. Quality
· Patient care is physician directed
· Incorporates evidence based guidelines and performance measures
o Preventive care
o Wellness care
o Acute illness and injury
o Chronic illness management
o End of life care
· Assess effective use of evidence-based guidelines and performance measures
· Supervision of patient care evidenced
o Medication review and update
o Appropriate ordering of diagnostic tests
o Appropriate management of medical referrals
· Assess and continuously improves services
o Measurements
o Quality studies
o Data trending
o Benchmarking
· Medical home studies – one each every three years
o Patient/physician relationship
§ Lab study
§ Patient/provider longevity of care
§ Frequency of appointment with the same provider/team
§ ID concurrently and on a prospective basis
o Continuity of care
§ Sample study to assess 50% of appointments with same team
o Comprehensiveness of care
§ Complete review of systems
§ Comparison of preventive versus episodic care
§ Comparison of referrals versus consultation
o Accessibility of care
§ Assess ICC and/or ER use
§ Wait times between appointments
§ Wait time at appointment
o Clinical study
§ Diabetes
§ Hypertension
· Electronic data management used as a tool for facilitating the standards
Updated 1.1.2015