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EPM Tools - Patient-Centered Medical Home Annual Questionnaires
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As part of SETMA’s Patient-Centered Medical Home, we annually complete five questionnaires for each patient seen to assess the following:

  • Fall Risk
  • Pain Assessment
  • Functional Assessment
  • Wellness
  • Stress

The standard is that each should be completed on all patients at least once a year and more frequently if a change in conditions dictates.  The Fall Risk should be completed on all patients over 50 and on younger patients who as a result of chronic condition are at risk of falling.
Provider performance on these questionnaires is publicly reported below. The content of the questions are as follows:

http://www.setma.com/epm-tools/images/Patient-Centered-Medical-home-annual-Questionaires_clip_image002.jpg

Once the Fall Risk Assessment is completed, the provider should, on the basis of the score, access the “Guidelines for Fall Precaution” and prepare a plan for preventing falls.

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http://www.setma.com/epm-tools/images/Patient-Centered-Medical-Home-Annual-Questionaires-content_clip_image006.jpg

Source -- Global Assessment of Functioning (GAF) Scale --  American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). doi:10.1176/appi.books.9780890423349.

http://www.setma.com/epm-tools/images/Patient-Centered-Medical-Home-Annual-Questionaires-content_clip_image008.jpg

(Source:  NIH. (2007). National Institutes of Health.  Pain Intensity Scales Retrieved January 17, 2007NIH. (2007). National Institutes of Health. Pain Intensity Scales  Retrieved January 17, 2007

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http://www.setma.com/epm-tools/images/Patient-Centered-Medical-Home-Annual-Questionaires-content_clip_image012.jpg

The Stress Assessment based on the Score


>=80 points

You have an excellent resistance to stress.

>=60 points

You may be somewhat vulnerable to stress.

<60 points

You may be seriously vulnerable to stress.

(Source: University of California, Berkley Wellness Letter, August 1995.  Scale Developers: Lyle Miller and Alma Dell Smith of Boston University Medical Center)

http://www.setma.com/epm-tools/images/Patient-Centered-Medical-Home-Annual-Questionaires-content_clip_image014.jpg
http://www.setma.com/epm-tools/images/Patient-Centered-Medical-Home-Annual-Questionaires-content_clip_image016.jpg

Wellness Assessment results based on the Score


< 5 points

Poor

5-9 points

Fair

10-19 points

Good

20-29 points

Very good

>=30 points

Excellent

(Source:   University of Wisconsin, Health Promotion and Human Development Department.  Developers: Anne Abbott, Jane P. Jones and John Munson)


SETMA I
2929 Calder
SETMA II
3570 College
Mark A. Wilson Clinic
2010 Dowlen
Nederland
2400 Highway 365
Orange
610 Strickland Drive
Lumberton
137 N LHS Drive

409-833-9797 888-833-0523

Office Hours: Monday through Thursday 8:00 AM to 5:30 PM and Friday 8:00 AM to 12:00 PM
If you need information about your healthcare, you may contact us by phone 24 hours a day, 7 days a week.