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	James L. Holly, M.D.

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EPM Tools - Patient-Centered Medical Home Annual Questionnaires

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:

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.

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.

(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

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)

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)

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