The RACI Tool- Defining Roles in a PCMH (1G1)

Legend

Role & Person
Deliverables / Tasks / Team Members
Provider / Nurse / MA / Front Desk / Practice Manager
Focus Area: Standard 1 Enhance Access and Continuity of Care
Timely response to messages before and after hours / R / R / R / R
Documenting advice in record / R / A / A / I / C
Understanding the use of EHR for 2 way communication / A / A / A / C / R
Patient empanelment in the EHR / A / A / A / A / R
Coordinate care across settings / A / A / R / A / A
Manage team roles and responsibilities / C / C / C / C / R
Sharing web based resources / R / R / R / I / C
Use Self-Management Techniques / R / R / R / I / C
Train in Communications Skills / R / R / R / R / R
Understand and use Population Health data / R / R / R / I / A
Participation in regular team meetings / R / R / R / R / A
Involvement in QI activities / R / R / R / R / A
Focus Area: Standard 2 Identify and Manage Patient Populations
Proper documentation entry and maintenance for patient EHR information / R / R / R / R / A
Use EHR to pull population level measures and reports / R / R / R / C / A
Identifies patient’s language needs and provides appropriate support / R / R / R / R / R
Regularly pulls EHR reports for population health / R / R / R / C / A
Electronic reach out to patients who need services / A / R / R / C / A
Focus Area: Standard 3 Plan and Manager Care
Pre visit and post visit planning / A / A / R / C / A
Refer patient to specialty and community care as needed / R / R / R / C / A
Medication Reconciliation / R / R / R / C / A
Providing care summaries and care plans / A / A / R / I / C
Focus Area: Standard 4 Provide Self Care Support and Community Resources
Self-Management and Motivational Interviewing techniques / R / R / R / C / C
Track referrals and outcomes / A / A / R / C / R
Maintain resource and referral list / C / C / C / C / R
Document Self Management Goals / A / A / R / I / C
Focus Area: Standard 5 Track and Coordinate Care
Track referrals and update EHR with pertinent information / A / A / R / A / A
Follow up with patients after utilization visits such as ED use / A / A / R / I / A
Follow up with inpatient or other facilities to coordinate care and gather pertinent history of care / A / A / R / I / A
Document patient and family input about specialist visits and history of other utilization / A / A / R / C / I
Focus Area: Standard 6 Identify and Manage Patient Populations
Focus Area Measure and Improve Performance
Participates in continuous quality improvement activities / R / R / R / R / R
Administer Patient Experience survey / C / C / C / C / A
Participate in Continuous Quality Improvement Science / A / A / A / A / R

Objectives

The RACI Matrix assists in identifying roles and cross-functional responsibilities for a project.

Tips for Adding PCMH responsibilities to a Job Description

  • Use as much of the direct language from the NCQA or other certifying entity as possible
  • Define how each role contributes to the management of population health and quality improvement
  • Consider writing a percentage of time in PCMH related activities as part of the Job Description


For example, an MA job description might include:

PCMH Participation and Coordination

  • Update and maintain current patient panels within the EHR
  • Use self-management and motivational interviewing techniques to engage patients in self care
  • Participate in continuous quality improvement efforts for preventative and chronic conditions as well as operational and workflow changes
  • Promote the role of the patient and practice within a PCMH including setting goals and assisting patient in understanding his or her care plan
  • Maintain updated records of all community resources
  • Lead and conduct pre-visit and post visit planning activities and follow up