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Patient-Centered Medical Home (PCMH)



CHADIS and Social Determinants of Health


The newest PCMH Standards address the need to gather important information about patients and families in order to provide the best care possible. As part of the focus on patient care, KM 01-02: Core Criteria requires advanced data collection including:


  • Medical histories

  • Family/social/cultural characteristics

  • Communication needs, social functioning

  • Social Determinants of Health

  • Developmental screening

Most of our clients already use CHADIS for data collection including medical histories, communication needs, social functioning, and developmental screening.


Did you know that CHADIS can also facilitate screening for Social Determinants of Health?


CHADIS offers the SEEK Plus questionnaire. The SEEK (the Safe Environment for Every Kid) project was developed to help primary care child health professionals address common psychosocial problems facing many families (parental depression, alcohol and substance abuse, domestic violence, major stress, and food insecurity). The SEEK Plus gathers additional information about problems that the caregiver selects and begins a few motivational interview questions so the parent can also tell the provider if they want help with any issues.


Addressing needs identified via the SEEK Plus: CHADIS offers a Patient Specific Template (PST) based on the SEEK Plus questionnaire. The PST provides interview wording suggestions for the provider to support motivational interviewing around the social determinants. The PST also presents resources that can be shared with families.


Evidence of Implementation: CHADIS can also provide reports and registries to demonstrate systematic use of the SEEK as well as document follow up by the provider.


CHADIS processes and data assist you in 2017 PCMH certification

  • All Bright Futures screens available- e.g., EPSDT, development, autism, obesity

  • Medical History documentation- e.g., Family History, Cardiac History, Medical History

  • Mental health screening for patient and family- e.g., PSC, PHQ-9, Edinburgh

  • Substance use screening for teens and families- e.g., CRAFFT, AUDIT, SEEK

  • Social Determinants of Health screening and resources e.g., SEEK, PRAPARE, SWYC, Food Insecurity

  • Health risk behaviors assessment- e.g., Smoking assessment, substance use

  • Shared decision making- graphics- eg asthma, ADHD, development

  • Community coordination- e.g., Teacher Vanderbilt, care coordination functionality

  • Medication adherence assistance- e.g.. asthma controller meds, ADHD

  • Chronic condition assessment as to need for a referral- e.g., asthma, ADHD

  • Patient satisfaction surveys- e.g., Pro- PHDS

  • Assessing health communication preferences e.g., JCAOH questionnaire, tools and handouts in Spanish

  • Care coordination functionality- to track referrals and kept appointments and sharing data securely for Integrated Behavioral Health

  • Quality Improvement processes- 5 MOC-4 programs with no chart review, custom MOC-4 programs can be created

  • Database created for PCMH and other regulation fulfillment

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