IMPORTANT GENERAL RECOMMENDATIONS: Refer to the following documents in addition to reviewing the questions and answers below related to specific standards, elements and factors: 1. PCMH 2011 Standards and Guidelines, the explanations and documentation requirements free on NCQA s Website 2. PCMH 2011 Record Review Workbook Instructions for details about PCMH 3C, 3D, 4A located in the PCMH 2011 Survey Tool 3. PCMH 2011 Clarifications located in the PCMH 2011 Standards and Guidelines Appendix 5 and in the Survey Tool 4. Submit additional questions to pcmh@ncqa.org PCMH 1A: Access During Office Hours The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: 1. Providing same-day appointments 2. Providing timely clinical advice by telephone during office hours 3. Providing timely clinical advice by secure electronic messages during office hours 4. Documenting clinical advice in the medical record. PCMH Standard 1: Enhance Access and Continuity 1. Is a practice expected to measure capacity to see patients or to assess the utilization of same day appointments, i.e., number of patients seen? 2. Must a practice provide both non-acute and urgent sameday appointments? 1. The practices is expected to show availability of same day appoinments which can be open appointment slots at the beginning of the day. The practice may measure utilization of same-day appointment access as an indication of need. The practice is expected to monitor the availability of same-day appontments against their documented process. 2. The practice is expected to show appointment slots that are available for both urgent/acute and routine care but may have a policy to accommodate patients with urgent/acute care needs first. PCMH 1 B: After Hours Access The practice has a written process and defined standards, and demonstrates that it monitors performance against the standards for: 1. Providing access to routine and urgent-care appointments outside regular business hours 2. Providing continuity of medical record information for care and advice when the office is not open 3. Providing timely clinical advice by telephone when the office is not open 3. Does a practice have to provide a minimum number of same day appointments? 1. How does NCQA define regular business hours? 2. If a practice is open one evening a week, does this qualify as outside of regular business hours?= 3. NCQA does not require a minimum number of same-day appointments per day for practices and not all clinicians need to offer same-day appointments to patients. The practice does need to have a written policy or process for staff ensuring that same day appointments are available, how patients can get them and then to provide a report of 5 days of the availability of same-day appointments. Third next available appointment and open access are examples of how same-day appointments may be provided. 1. The practice is expected to offer access to routine and non-routine care outside of regular business for the patients/families to help avoid requiring them to take time from work and school to address their health care needs. This may include early morning, evenings or weekends to accommodate patients and families. The practice may arrange for patients to be seen by other facilities or clinicians if it does not provide appointments outside of regular business hours. 2. Yes, being open one evening a week qualifies as outside regular business hours. Updated 9/24/13 1
4. Providing timely clinical advice using a secure, interactive electronic system when the office is not open 5. Documenting after-hours clinical advice in patient records. 3. If the practice offers patients nights and weekend coverage through a phone call service staffed by RNs to handle patient questions, does this meet the requirements? Our patients may be referred to a local ER or urgent care center with which the practice has an agreement. 3. The phone call service provides patients with after-hours access (Factor 3), but does not address the issue of access outside of regular business hours. Referring a patient to an urgent care center or ER may meet the requirements if routine and urgent care appointments are available at either of these facilities AND the cost to the patient and payer is no different than it would be for an office visit at the practice site. 4. Does a solo provider need a formal agreement for after hours or urgent care? 5. Will a hospital-owned practice with an emergency department that serves as an after-hours clinic meet the requirements? Does the practice need to have a formal agreement if after-hours care is provided by other clinicians, practices or facilities? Factor 3 Is it acceptable to provide documentation of two-five-day logs with NO after-hours calls? The patient portal has a message telling patients that patient requests for clinical advice will be responded to the next business day AND that the patient should contact the oncall provider when the office is closed. Does this meet the intent of the requirement? 4. No, a small practice with limited staffing may arrange for patients to receive care from other (non- ER) facilities or clinicians as long as the information is clearly conveyed to patients. 5. requires the practice to offer appointment hours beyond the traditional business hours for both routine and urgent care needs, for example, early morning, Saturday, evening hours. Using the ER does not meet this requirement unless patients can access routine appointments at the ER. No. It is up to the practice to determine the best way to manage that documented process for staff to follow for arranging after-hours access with other practices or clinicians and provide a report showing after-hours availability or materials communicating practice hours. The standards do not state that a formal agreement must be in place. Factor 3 The practice is expected to have a documented process for handling after-hours calls, to identify when these calls typically come in and to collect data on at least five-days of calls. The practice must select a time period when calls come in so that it can demonstrate how the process is met. Yes, as long as there is an available on-call provider and the response time is stated. The practice is expected to track the response times. Updated 9/24/13 2
PCMH 1C: Electronic Access The practice provides the following information and services to patients and families through a secure electronic system. 1. More than 50 percent of patients who request an electronic copy of their health information (including problem list, diagnoses, diagnostic test results, medication lists, allergies) receive it within three business days 2. At least 10 percent of patients have electronic access to their current health information (including lab results, problem list, medication lists, and allergies) within four business days of when the information is available to the practice 3. Clinical summaries are provided to patients for more than 50 percent of office visits within three business days 4. Two-way communication between patients/ families and the practice 5. Request for appointments or prescription refills 6. Request for referrals or test results PCMH 1D: Continuity The practice provides continuity of care for patients/ families by: 1. Expecting patients/families to select a personal clinician 2. Documenting the patient s/family s choice of clinician 3. Monitoring the percentage of patient visits with a selected clinician or team. Factor 5 Is it acceptable for the on-call provider to call the practice the following day and for the PCP s nurse to document the message in the patient s EHR? Factors 4-6 Is a screenshot of the webpage showing available practice activities sufficient documentation for Factors 4-6? How should residency clinics handle clinician selection? Factor 5 Yes, as long as the practice has a documented process for recording both electronic and telephone advice in the patient s medical record. -6 Documentation is a screen shot demonstrating system capability. This could be the portal page of a Web page (showing that the portal is secure) and screenshots for each factor or one page if it shows all the activities (secure two-way communication, requesting medication refills or appointments and requesting a referral or test). It must be clear from the screenshot that this is an active website for the practice. Patients should be offered the option of choosing a team that would be under the direction of a staff or supervising physician. The chosen personal clinician would not be the resident since the resident will move to another rotation and will no longer be associated with the clinic. Updated 9/24/13 3
PCMH 1E: Medical Home Responsibilities The practice has a process and materials that it provides patients/families on the role of the medical home, which include the following: 1. The practice is responsible for coordinating patient care across multiple settings 2. Instructions on obtaining care and clinical advice during office hours and when the office is closed 3. The practice functions most effectively as a medical home if patients/families provide a complete medical history and information about care obtained outside the practice 4. The care team gives the patient/family access to evidence-based care and self-management support PCMH 1F: Culturally and Linguistically Appropriate Services The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by: 1. Assessing the racial and ethnic diversity of its population 2. Assessing the language needs of its population 3. Providing interpretation or bilingual services to meet the language needs of its population 4. Providing printed materials in the languages of its population Our practice brochure only had a statement about the practice use of evidence- based guidelines and tools to care for the patient. What does a practice need to provide to patient/families? 1. What data is required to show assessment of racial and ethnic diversity? 2. Can we use state-wide data to document race and ethnicity? The practice is expected to provide the patient with care that is based on current evidence, an indication of up-to-date evaluation and treatment guidelines. Patients may be provided this assurance in the materials and information used by the practice. 1. Reports of the data specified in each factor but NCQA does not specify the period of data collection. 2. No. The data needs to reflect the local community served by the practice. Updated 9/24/13 4
PCMH 1G: The Practice Team The practice uses a team to provide a range of patient care services by: 1. Defining roles for clinical and nonclinical team members 2. Having regular team meetings or a structured communication process 3. Using standing orders for services 4. Training and assigning care teams to coordinate care for individual patients 5. Training and assigning care teams to support patients and families in self-management, selfefficacy and behavior change 6. Training and assigning care teams for patient population management 7. Training and designating care team members in communication skills 8. Involving care team staff in the practice s performance evaluation and quality improvement activities What is an acceptable regular team meeting, and does it need to include the clinician? Factors 4-7 1. What is adequate care team training? 2. Do all members of the care team need to be included in the trainings? During a huddle, the care team can identify patients on the day s schedule with unmet care needs beyond the stated reason for the visit. To do this well, the team will learn how to quickly scan charts for care gaps while keeping huddles to five minutes (registries are very helpful here). The team can then extend itself to address those needs, eliminating the need for early follow-up and/or missed opportunity to close gaps in care. http://www.safetynetmedicalhome.org/sites/default+/files/implementation-guide-enhanced- Access.pdf All members of the practice care team should be included which includes the clinicians. If it s a large practice, there may be more than one care team but its members of a team/pod etc. that work together to provide care for patients and should include the primary care clinicians. Documentation must include a documented process and examples of team communication such as a morning team huddle or a targeted email exchange about patient care. This may include an appointment list, a tracking or flow sheet provided to each team member, meeting minutes, emails showing that the whole care team is involved Examples: 1) Army Medical Department PCMH Huddle Video http://www.youtube.com/watch?v=q84aaemv4c4 2) Small Practice Planned Care Huddle http://www.youtube.com/watch?v=wttxm7janb4 Factors 4-7 1. NCQA does not propose a specific method for training care team members; training should address the services described in each factor and to the staff of the assigned team. It can be part of staff orientation or given at regularly scheduled intervals. 2. No, not all care team members need to perform the services in Factors 4-7, just individuals who assume and are trained for these responsibilities as part of their job description. Factors 4-7 emphasize the need for identifying and training specific care team members for patient care services within the medical home. For documentation of these factors, the practice must provide: o o Position descriptions of team members who provide the services or a policy describing team member responsibilities related to Factors 4-7 and Description of the training and a training schedule or materials PCMH 2: Identify and Manage Patient Populations Updated 9/24/13 5
PCMH 2A: Patient Information The practice uses an electronic system that records the following as structured (searchable) data for more than 50 percent of its patients. 1. Date of birth 2. Gender 3. Race 4. Ethnicity 5. Preferred language 6. Telephone numbers 7. E-mail address 8. Dates of previous clinical visits 9. Legal guardian/health care proxy 10. Primary caregiver 11. Presence of advance directives (NA for pediatric practices) 12. Health insurance information PCMH 2B: Clinical Data The practice uses an electronic system to record the following as structured (searchable) data. 1. An up-to-date problem list with current and active diagnoses for more than 80 percent of patients 2. Allergies, including medication allergies and adverse reactions, for more than 80 percent of patients 3. Blood pressure, with the date of update for more than 50 percent of patients 2 years and older 4. Height for more than 50 percent of patients 2 years and older 5. Weight for more than 50 percent of patients 2 years and older 6. System calculates and displays BMI (NA for pediatric practices) 7. System can plot and display growth charts (length/height, weight and head circumference (less than 2 years of age) and BMI percentile (2 1 Does a copy of the advance directive signed by the patient need to be included in the patient s medical record? Factor 8 If our Meaningful Use report includes smoking status, does this meet the documentation requirement? 1 No, the signed directive does not need to be included in the patient s medical record. Factor 8 Yes, but the practice the practice should include in the comment box in the Survey Tool or a text box on the report that tobacco use (not just smoking status) is recorded in this field. Updated 9/24/13 6
20 years) (NA for adult practices) 8. Status of tobacco use for patients 13 years and older for more than 50 percent of patients (NA for pediatric practices if all patients 9. List of prescription medications with the date of updates for more than 80 percent of patients PCMH 2C: Comprehensive Health Assessment To understand the health risks and information needs of patients/families, the practice conducts and documents a comprehensive health assessment that includes: 1. Can the example of a completed health assessment be from one patient or different sections from multiple patients? 1. The documentation requirement for PCMH 2C states that the practice may show a completed patient assessment (de-identified) documenting the factors included in the health assessment. If it is not possible to show this information for a single patient, the practice must explain how this data is collected for all patients. If the patient population includes adults and pediatrics, the practice is encouraged to provide documentation for both. 1. Documentation of age- and gender-appropriate immunizations and screenings 2. Family/social/cultural characteristics 3. Communication needs 4. Medical history of patient and family 5. Advance care planning (NA for pediatric practices) 6. Behaviors affecting health 7. Patient and family mental health/substance abuse 8. Developmental screening using a standardized tool (NA for practices with no pediatric patients) 9. Depression screening for adults and adolescents using a standardized tool. PCMH 2D: Use Data for Population Management The practice uses patient information, clinical data and evidence-based guidelines to generate lists of patients 2. Can a smart forms be used? Factor 7 Must the practice assess both mental health AND substance abuse of the family? Factor 9 1. Please clarify screening for adults for depression when staff-assisted depression care support systems are in place to assure accurate diagnosis, effective treatment and followup? 2. Can a practice decide on the frequency of depression screening if it s within the parameters of clinical guidelines? 1. What are options for three preventive services or 2. If you use a form or any other process to demonstrate how your practice consistently collects, conducts and documents a comprehensive health assessment for each factor, the documentation must clearly show how these factors are collected consistently. The practice should have a process that explains how the forms are used. A blank form is not acceptable. Factor 7 The practice should ask about the mental health and substance abuse of both the patient and family based on relevance for the patient. Factor 9 1. The U.S. Preventive Services Task Force (USPSTF) states that adults and adolescents should be screened for depression when the practice has access to services that can be used if there is a positive result. For example, mental health providers, within the practice or external to the practice, to whom the practice can refer patients. If the practice does not screen for depression, N/A is not an option. The practice needs to respond no. 2. Yes, the frequency is up to the discretion of the practice as long as it follows evidence-based guidelines. 1. The following are acceptable options for preventive services for adult patients: An adult practice may identify lists of patients needing: Updated 9/24/13 7
and to proactively remind patients/ families and clinicians of services needed for: 1. At least three different preventive care services++ 2. At least three different chronic care services ++ 3. Patients not recently seen by the practice 4. Specific medications. screenings, based on age? o Immunizations (such as flu shots, pneumonia vaccine or shingles vaccine, tetanus); only one adult immunization service may be used to meet this requirement. o Screenings (such as mammograms, colo-rectal screening). o Check-up visits, annual lab testing, well women visits Preventive measures must encompass a practice s entire appropriate population, not only patients with chronic conditions. The intent of preventive measures is for the practice to use their systems to identify specific groups of patients and to improve the quality of care for all patients in the practice. ( focuses on the chronic condition populations.) For example, the flu vaccine, the practice needs to demonstrate that it proactively identified and provided outreach to the patients for which flu vaccine is an evidence-based recommendation. The reports or lists of patients needing services must be generated within the past 12 months and there must be demonstration of how the patients are notified for each service. Practices with both adult and pediatric patients may use immunizations for only one age group, not one for pediatric patients and one for adults. for pediatric practices Practices must identify three different preventive care services, not just immunizations. Pediatric immunizations may count as only one service. For example, for three different preventive care services, a practice may use: 1) Vaccinations 2) Developmental screening 3) Autism screening 4)Well-child checkups A practice may NOT use different age groups of patients behind on vaccinations, such as 2-yearolds, 6-year-olds and 12-year-olds? AAP Resources Recommendations for Preventive Pediatric Health Care (PDF): http://brightfutures.aap.org/pdfs/aap%20bright%20futures%20periodicity%20sched%20101107.p df Interactive Periodicity Schedule (AAP Pediatric Care Online- Web resource): https://www.pediatriccareonline.org/pco/ub/periodicity Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition (Web site and links to associated text/materials): http://brightfutures.aap.org/index.html 2. Can annual exams for adults AND well-child visits be used? 2. A practice that sees both adult and pediatric patients may not use two age groups of patients for well-ness checks (annual exams, well-child visits). The practice may use one group. 3. Can HbA1c be used? 3. No, HbA1c is appropriate for that is, chronic care services, but not for preventive care Updated 9/24/13 8
Can the practice illustrate the three services based on only one chronic condition? Factor 3 Are the following acceptable registries of patients: 1. Established patients who did not keep appointments services (Factor1). The practice may use one chronic condition for all three chronic care services or may use two or three conditions. Factor 3 1. The practice can identify patients who have not kept scheduled appointments and show implementation of a follow-up process. Alternatively, the practice may use other criteria to identify patients who have not been seen lately. For example, the practice may identify patients they define as high risk who have not had an office visit for a specified period of time, and show outreach to this group. 2. Patients who are managed care patients but have never been seen by the practice? What types of medications are appropriate for this factor? Factors 1-4 1. How many reports must a practice submit to meet 2D, Factors 1-4? 2. If the patient has never been seen by the practice but presumably has been assigned to the practice by a health plan, they cannot be considered part of the practice s patient population. Thus, this group would not meet the requirement for Factor 3. The practice should be able to identify all patients on such prescriptions and show implementation of an outreach program. The clearest example is medication for which the Food and Drug has issued a recall or safety warning. Practices should be aware of the potentially serious side effects of medications they prescribe and require regular monitoring such as anticoagulants. The practice may also identify patients who are taking pain medications, length of time they ve been taking it and potential side effects. Factors 1-4 1. Documentation for 2D, Factors 1-4 must include: Reports or lists of patients needing services generated within the past 12 months. Factors 1 and 2 require at least three different services and Materials showing how patients are notified. 2. Does a practice need to provide a separate letter, phone script or other method for each service needed. 2. If the same method is used for each service, and the practice provides an example, the practice must include information about how the letter, phone script or other method is modified for each service reminder. PCMH 3: Plan and Manage Care Updated 9/24/13 9
PCMH 3A: Implement Evidence-Based Guidelines The practice implements evidence-based guidelines through point-of-care reminders for patients with: 1. The first important condition 2. The second important condition 3. The third condition, related to unhealthy behaviors or mental health or substance abuse. Factors 1,2,3 1. What is a resource for evidence-based guidelines? 2. If a practice chooses three conditions in 3A but does not identify high-risk patients in 3B, what conditions should be used to meet 3C, 3D and 4A? Factors 1,2,3 1. Resources for evidence-based guidelines: Up-to-Date - www.uptodate.com National Guideline Clearinghouse - http://www.guideline.gov/ These references are not meant to be all inclusive. Other sources may be acceptable. 2. The practice will use the three conditions identified in 3A to select patients for the chart review required in 3C, 3D and 4A. PCMH 3B: Identify High-Risk Patients To identify high-risk or complex patients, the practice: 1. Establishes criteria and a systematic process to identify high-risk or complex patients 2. Determines the percentage of high-risk or complex patients in its population. 3. How should important conditions be selected if the practice has both pediatric and adult patients? Factor 3 Why is Factor 3 a critical factor? 1. How can a practice identify high risk patients? 2. Is it acceptable to use age 65 3. It is recommended that the practice select conditions representative of the practice s patient population, for example, the practice may choose one pediatric condition and one adult condition; the third condition may be either pediatric or adult. Do remember that one of the three conditions must be related to unhealthy behaviors but it may be either pediatric or adult. Factor 3 This is a critical factor to help emphasize the strong link between physical health, acute and chronic conditions and unhealthy behaviors, mental health and substance abuse in patients needing care planning, medication management and patient self-care. 1. The practice may identify patients through a billing or practice management system or electronic medical record; through key staff members; or through profiling performed by a health plan, if profiles provided by the plan(s) represent at least 75 percent of the patient population. The criteria for identifying complex or high-risk patients are suggested in the PCMH 2011 Standards and Guidelines. IMPORTANT NOTE: While some practices may have a greater number of high-risk patients, not all of the patient population should be identified as high-risk. If the majority of patients are more complex and thus potentially at higher risk, the practice should identify a sub-set of these patients at greatest risk. Pediatric populations Practices may identify children and youth with special health care needs who are defined by the U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) as children who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services of a type or amount beyond that required generally. 2. Using ONLY age 65 years and older is not an acceptable criterion for identifying high risk patients. Updated 9/24/13 10
years and over as a criteria for high risk patients? Factors 1 and 2 1. Can a practice skip 3B and still get credit in 3C, 3D and 4A? Older patients (e.g., over age 65 years) may be combined with other high risk criteria such as comorbid conditions, frequent hospitalizations, mental health problems or frailty. Factors 1 and 2 1. If a practice chooses not to identify high risk/complex patients: For 3C, 3D and 4A, the practice will need to use patients identified with conditions in 3A and may earn full credit. However, if a practice completes 3B, it must include the patients identified as high risk/complex in the chart review required for 3C, 3D and 4A or credit for 3B will be denied. PCMH 3C: Care Management The care team performs the following for at least 75 percent of the patients identified in Elements A and B. 1. Conducts pre-visit preparations 2. Collaborates with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit 3. Gives the patient/family a written plan of care 4. Assesses and addresses barriers when the patient has not met treatment goals 5. Gives the patient/family a clinical summary at each relevant visit 6. Identifies patients/families who might benefit from 2. Is it acceptable to get data from external sources such as health plans? 3. Are evidence-based guidelines and point-of-care reminders required for high-risk/complex patients? What is included in pre-visit planning? 2. Data from external sources may be used to identify high-risk/complex patients if the pool of patients being assessed represents 76% of the practice population. 3. No, only what is required in 3B, Factors 1 and 2. If your identified high-risk patients have chronic conditions or unhealthy behaviors, the evidence-based guidelines would be necessary for the care management Factors in PCMH3C, but not in 3B. The goal of pre-visit planning is to prepare for an efficient, quality patient visit. It may include documenting: 1. Patient contacted? 2. Demographics update? 3. Medication update? 4. Refills needed? 5. Consult visits, ER visits and/or hospital stay since the last appointment 6. Lab/X-rays completed? 7. Self-care tools completed and available to bring to the visit? 8. Need for a longer visit? To respond yes in the Record Review Workbook, results of the pre-visit assessment taking place or comments must be in each patient chart. Updated 9/24/13 11
additional care management support 7. Follows up with patients/families who have not kept important appointments What are the parameters for a care plan? 4. A care plan is based on the acute, chronic and preventive care needs of the patient and needs to include treatment goals and status. May go back as far as 1 year +/- a 2 month grace period. NCQA requires consistent EHR documentation in support of PCMH activities for the past 3 months. The care plan may come from any relevant patient note (endocrine, primary care, behavioral health, etc.)? The factor is meant to document a patient centered view of the care plan. A care plan does not need to be recreated (by the PCP, e.g., after a specialist visit or after a robust PCP plan of care is documented) at each visit but should be reviewed/updated. PCMH 3D: Medication Management The practice manages medications in the following ways. Factor 3 Is a clinical summary sufficient as a plan of care Does there need to be documentation of both assessing and addressing barriers to meeting treatment goals? Factors 2, 3, 6 What must be documented in the medical record if the patient meets treatment goals and if additional care management is NOT needed? How frequently does medication reconciliation need to occur? Factor 3 A clinical summary is not a plan of care. A clinical summary might include a diagnosis, medications, recommended treatment and follow-up, and information about home management of an acute or chronic condition, when appropriate. A plan of care is tailored for the patients use at home and to the patient s understanding (e.g. asthma action plan). However, it may be added to the clinician summary. Yes, if the patient has not met treatment goals and there is no change in the treatment plan summary, it can be marked NA if meeting goals. The assessment should be reviewed and barriers addressed in a manner to increase progress. Factors 2, 3, 6 : If there are no changes in the patient s status at relevant visits, the practice is expected to document that there are no changes in the care plan and that the patient is meeting treatment goals. Factor 3: The practice is expected to document in the medical record at relevant visits that the patient has been provided a copy of the care plan at some time in the last 12 months +/ 2 month grace period. If there are no changes in the care plan, the record should reflect this. Factor 6: The patient record should reflect that this patient does not need additional care management support. Medication reconciliation should occur either at transitions of care or at least annually. Updated 9/24/13 12
1. Reviews and reconciles medications with patients/families for more than 50 percent of care transitions 2. Reviews and reconciles medications with patients/families for more than 80 percent of care transitions 3. Provides information about new prescriptions to more than 80 percent of patients/families 4. Assesses patient/family understanding of medications for more than 50 percent of patients with date of assessment 5. Assesses patient response to medications and barriers to adherence for more than 50 percent of patients with date of assessment 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50 percent of patients/families, with the date of updates PCMH 3C: Care Management PCMH 3D: Medication Management PCMH 4A: Support Self-Care Process Patient-Centered Medical Home (PCMH) 2011 Factors 1 and 2 What is the difference between Factors 1 and 2? Factor 3 1. Are excerpts from medical records indicating that medications and side effects were reviewed with the family acceptable documentation, or is a specific medication handout necessary? 2. Does supplying information on all new prescriptions duplicate information provided by a pharmacy? 3. Does this refer only to medications relevant to a specific disease of interest? What constitutes documentation in the medical record of assessing patient understanding of medications? Factor 5 Does the practice assess response to the medication relevant to treating the disease of interest? 3C, 3D, 4A 1. Can Meaningful Use reports be used to meet some factors in these three elements instead of the Record Review Workbook (RRWB)? Factors 1 and 2 is Meaningful Use, however if a practice is meeting the 80th percentile, it can get credit for both factor 1 and factor 2. Factor 3 1. Excerpts from medical records noting that medications and side effects were reviewed with the patient/family suffice. 2. Practices have a responsibility to ensure that patients/families understand why medication was prescribed and the medication s benefits to the patient. Parents might not review prescription information provided by a pharmacy, and information might not be tailored to the needs of the child, the parents or the household. 3. Providing new medication information is not specific to a relevant condition. It applies to all new medications the patient is taking. If medical note mention patient concerns about the risks of a medication, can use as evidence of this factor. Factor 5 The practice is expected to ask about any medication prescribed to the patient and assess efficacy. 3C, 3D, 4A 1. Yes, but this would only apply to Meaningful Use requirements: 3C, Factor 5, 3D, and 4A,. Apart from these three factors, the practice must provide data in the RRWB or use the instructions for Method 1, detailed in 3C, 3D and 4A in the PCMH 2011 Standards and Guidelines. 2. What must be documented in the patient s record if a diabetes patient has been wellcontrolled for >20 years? 2. At relevant visits, the practice is expected to document that there are no changes in care management, medication management or self-support. However, though the patient is wellcontrolled, the practice is also expected to periodically reassess the patient and determine if changes are needed. Updated 9/24/13 13
PCMH 3E: Use Electronic Prescribing The practice uses an electronic prescription system with the following capabilities. 1. Generates and transmits at least 40 percent of eligible prescriptions to pharmacies 2. Generates at least 75 percent of eligible prescriptions 3. Enters electronic medication orders into the medical record for more than 30 percent of patients with at least one medication in their medication list 4. Performs patient-specific checks for drug-drug and drug-allergy interactions 5. Alerts prescribers to generic alternatives 6. Alerts prescribers to formulary status PCMH 4A: Support Self-Care Process The practice conducts activities to support patients/families in self-management: 1. Provides educational resources or refers at least 50 percent of patients/families to educational resources to assist in self-management 2. Uses an EHR to identify patient-specific education resources and provide them to more than 10 percent of patients, if appropriate 3. Develops and documents self-management plans and goals in collaboration with at least 50 percent of patients/families 4. Documents self-management abilities for at least 50 percent of patients/families 5. Provides self-management tools to record selfcare results for at least 50 percent of patients/families 6. Counsels at least 50 percent of patients/families Patient-Centered Medical Home (PCMH) 2011 1. What if the practice cannot write all prescriptions electronically? 2. What if we have no way to determine the number of handwritten prescriptions? Do the patient-specific checks for drug-drug and drug-allergy interactions warnings have to be pop-ups or can any format meet this factor? 1. NCQA requirements allow for prescriptions that are not permitted to be prescribed electronically. 2. NCQA offers an alternate documentation method for. The practice must provide: Prescribing process/policy including how the practice ensures the avoidance of hand-written prescriptions and Report showing the total number of patients seen in the past 12 months (or a recent 3-month period if the practice does not have 12 months of electronic data) and the number of eligible prescriptions generated by the practice using the electronic prescribing system during the same time period and Explanation of how this calculation meets the 75% requirement Should be a screen shot. Does not have to show a real patient it can be a dummy report. It needs to be proactive or automatic prompt as part of the workflow. Does not necessarily need to be a pop up. It is not met if they have to go to another system or look it up separately. PCMH 4: Provide Self-Care Support and Community Resources Is documentation in the medical record required for educational materials, programs or resources? Yes. Documentation in the medical record noting educational materials provided to the patient may be anytime in the past 12-14 month period. Updated 9/24/13 14
to adopt healthy behaviors PCMH 4B: Provide Referrals to Community Resources The practice supports patients/families that need access to community resources: Patient-Centered Medical Home (PCMH) 2011 1. Can an agency be listed more than once as a resource for the five community service areas? 1. Yes, an agency may be listed for more than one service area. The expectation is that there will be more than one resource for each of the five topics or service areas. 1. Maintains a current resource list on five topics or key community service areas of importance to the patient population 2. Tracks referrals provided to patients/families 3. Arranges or provides treatment for mental health and substance abuse disorders Offers opportunities for health education programs (such as group classes and peer support). 2. Can resources requiring a provider order be included? 2. It is important that the services areas reflect the needs of the patient population and support patient self-care or access to care and are reasonably accessible to the patient/family. However, the standards do not explicitly state that community resources should not require a provider order unless appropriate. PCMH 5A: Test Tracking and Follow-Up The practice has a documented process for and demonstrates that it: 1. Tracks lab tests until results are available, flagging and following up on overdue results 2. Tracks imaging tests until results are available, flagging and following up on overdue results 3. Flags abnormal lab results, bringing them to the attention of the clinician 4. Flags abnormal imaging results, bringing them to the attention of the clinician 5. Notifies patients/families of normal and abnormal lab and imaging test results 6. Follows up with inpatient facilities on newborn hearing and blood-spot screening (NA for adults) 7. Electronically communicates with labs to order tests and retrieve results 8. Electronically communicates with facilities to order and retrieve imaging results 9. Electronically incorporates at least 40 percent of all clinical lab test results into structured fields in medical records 10. Electronically incorporates imaging test results Factors 1-10 What is the minimal information required to pass the 5A laboratory and radiology factors? Factor 8 vs. 0 How does 0 differ from Factor 8 where the practice PCMH 5: Track and Coordinate Care Factors 1-10 PCMH 5A is not a Must Pass element so there is no minimum data requirement. To receive 100% of the available points, the practice must meet at least 8 factors, including Factors 1 and 2. Practices need to consider the documentation requirements for each factor and determine if the supporting documents meet the intent of the requirements as shown in the PCMH 2011 Standards and Guidelines. Factor 8 vs. 0 If a practice has an EHR and shows a screen shot of the EHR order screen and report they should receive credit. There should be a description as well as a screen shot. Updated 9/24/13 15
into medical records. PCMH 5B: Referral Tracking and Follow-Up The practice coordinates referrals by: 1. Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information 2. Tracking the status of referrals, including required timing for receiving a specialist s report 3. Following up to obtain a specialist s report 4. Establishing and documenting agreements with specialists in the medical record if comanagement is needed 5. Asking patients/families about self-referrals and requesting reports from clinicians 6. Demonstrating the capability for electronic exchange of key clinical information (e.g., problem list, medication list, allergies, diagnostic test results) between clinicians 7. Providing an electronic summary of the care record to another provider for more than 50 percent of referrals. PCMH 5C: Coordinate With Facilities/Care Transitions On its own or in conjunction with an external organization, the practice systematically: 1. Demonstrates its process for identifying patients with a hospital admission and patients with an emergency department visit 2. Demonstrates its process for sharing clinical information with the admitting hospitals and or emergency departments 3. Demonstrates its process for consistently obtaining patient discharge summaries from the hospital and other facilities 4. Demonstrates its process for contacting patients/families for appropriate follow-up care Patient-Centered Medical Home (PCMH) 2011 electronically communicates with facilities to retrieve imaging results? Factors 1-3 1. What are the documentation requirements for Factors 1 3? 2. What are the documentation requirements if the PCPs and specialists use the same integrated EMR? 5 B, Factor 7 5 C, Factor 8 Can a practice use a report that includes referrals and care transitions combined? 1. Do we need to show that we can identify all patients who have been admitted to the hospital and treated in the emergency room? 2. Can hospitalization and emergency room visit data from health plans meet this requirement? Factor 7 How does the practice demonstrate the capability for the electronic For factor 8 a practice without an EHR can earn credit if they can access another system and get those results electronically. So a practice can receive credit for Factor 8 but not necessarily for 0. Factors 1-3 1. Documentation requirements include: requires a written/documented process or procedure that describes how the specialist is provided the clinical reason and pertinent patient information needed to proceed with the referral. The documentation should include an example of how the practice follows its documented process. Factors 2 and 3 require a written/documented process describing how the practice follows up on referrals. The documentation should include a system generated report or a log (manual or electronic) that has at least 1 week of activity (referrals) to show how the referral tracking procedure is being followed. The log should include patient ID (blinded), referral date, provider/facility patient was referred to, tracking status to indicate whether report was received, is pending or overdue (urgency and timing) and follow up if the report is overdue. 2. The practice is expected to have a documented process specifying how the specialist will be notified of the referral request, important information related to the patient, how the status of the referrals will be tracked, including the specialist s report. The use of the same EMR does not mean the practice can avoid having a documented process or tracking system, including follow-up to review the specialist s report. 5 B, Factor 7 5 C, Factor 8 Your practice can link the same document to both elements. The reports, designed for Meaningful Use, are for care transitions or referrals. The results must be provided for the practice or 75% of the providers and must show results of 51% or more. 1. The practice must have a documented process for identifying hospitalized patients and those who have been treated in the emergency room and A log or report demonstrating that patients have been identified and represent those facilities used most often by the practice s patients. 2. A practice may use timely health plan data (data that is provided at least weekly) for identifying patients, if 75% of the patient population is represented by the health plan. The practice may use data from more than one health plan as long as collectively the plans represent at least 75% of the practice population. Factor 7 There must be interconnectivity between the practice and facilities in order to exchange clinical information. The practices can demonstrate via screenshots showing a test of the capability of the Updated 9/24/13 16
within an appropriate period following a hospital admission or emergency department visit 5. Demonstrates its process for exchanging patient information with the hospital during a patient s hospitalization 6. Collaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult care (NA for adult-only or family medicine practices) 7. Demonstrates the capability for electronic exchange of key clinical information with clinicians in facilities 8. Provides an electronic summary-of-care record to another care facility for more than 50 percent of transitions of care. PCMH 6A: Measure Performance The practice measures or receives data on the following: 1. At least three preventive care measures 2. At least three chronic or acute care clinical measures 3. At least two utilization measures affecting health care costs 2. 4. Performance data stratified for vulnerable populations (to assess disparities in care). PCMH 6B: Measure Patient/Family Experience The practice obtains feedback from patients/families on their experiences with the practice and their care. 1. The practice conducts a survey (using any instrument) to evaluate patient/ family experiences on at least three of the following categories: Access Communication Coordination Whole-person care/self-management support Patient-Centered Medical Home (PCMH) 2011 exchange of key clinical information with facilities? 5 B, Factor 7 5 C, Factor 8 Can a practice use a report that includes referrals and care transitions combined? Factors 1 and 2 Which patient populations should be used to to meet the specified measures How can a practice stratify data for vulnerable populations? 1. Is a practice required to use the Consumer Assessment of Healthcare Providers and Systems Patient-Centered Medical Home (CAHPS PCMH) Survey to meet? 2. How many patients does the practice have to survey? certified EHR to exchange clinical information. If the facility doesn t have capacity the test will only show the practice s system side of the test. 5 B, Factor 7 5 C, Factor 8 Your practice can link the same document to both elements. The reports, designed for Meaningful Use, are for care transitions or referrals. The results must be provided for the practice or 75% of the providers and must show results of 51% or more. PCMH 6: Measure and Improve Performance Factors 1 and 2 Preventive measures and patient experience measures should encompass a practice s entire population and should not be limited to patients with chronic conditions. Chronic or acute care measures should be based on evidence-based guidelines. Practices should select a vulnerable population for measurement using fields that are available in their practice system. Practices may use categories such as race, age, ethnicity, language needs, education, income, type of insurance, disability or health status to identify specific populations that may potentially experience disparities in care. 1. The CAHPS PCMH Survey is not required to meet this factor. The practice may use its own survey, which must include questions related to three of the four categories specified in the standards (access, communication, coordination, whole-person care/self-management support). 2. There is no specified sample size or frequency. NOTE: Distinction in Patient Experience Reporting is not required for Recognition. There are additional requirements to receive this designation, which include using an NCQAcertified survey vendor to submit data on behalf of the practice. See the Q&A below for additional Updated 9/24/13 17
2. The practice uses the CAHPS Patient-Centered Medical Home (PCMH) survey tool 3. The practice obtains feedback on the experiences of vulnerable patient groups 4. The practice obtains feedback from patients/families through qualitative means. Patient-Centered Medical Home (PCMH) 2011 information. The CAHPS PCMH adult and pediatric surveys are available free of charge from AHRQ. Link to the Agency for Healthcare Research and Quality' (AHRQ) CAHPS PCMH website: https://cahps.ahrq.gov/clinician_group/cgsurvey/aboutpatientcenteredmedicalhomeitemset.pdf 1. If the practice uses the CAHPS PCMH Survey without modifying the questions or changing the length of the survey, it will satisfy the requirements for Factors 1 and 2. 1. Will the CAHPS PCMH Survey meet both Factors 1 and 2? 2. Will the CAHPS PCMH survey meet both Factors 1 and 2 if the practice does not use an NCQA certified survey vendor? 3. If a practice uses an NCQA certified survey vendor who will submit data for the practice, will the practice also receive credit for Factors 1 and 2 in addition to earning Distinction in Patient Experience Reporting? 4. Can the practice use a subset of the CAHPS PCMH Survey? 5. How long does a practice have to use patient experience data that is collected bi-annually? 6. Is Distinction required for PCMH Recognition? 7. What is Distinction in Patient Experience Reporting? 2. Yes. If the practice uses the CAHPS PCMH Survey without modifying the questions or changing the length of the survey, it will satisfy the requirements for Factors 1 and 2. 3. Practices will receive credit for Factors 1 and 2 if they provide CAHPS PCMH results in their PCMH Survey Tool. They will also receive Distinction if they achieve PCMH Recognition. 4. The practice must use the entire CAHPS PCMH Survey to satisfy the requirements of. A subset of CAHPS PCMH Survey questions may be used to satisfy (if the 3 category requirement is met) but this will NOT meet. 5. The practice has up to 12 months to use patient experience data to meet the PCMH 2011 requirements. 6. Practices applying for PCMH Recognition do not need to earn Distinction in Patient Experience Reporting to achieve Recognition as a PCMH. 7. NCQA developed the optional Distinction in Patient Experience Reporting to help practices capture patient and family feedback through the CAHPS PCMH Survey. The CAHPS PCMH Survey assesses several domains of care: Access Information Communication Coordination of care Comprehensiveness Self-management support and shared decision making. To receive Distinction practices must submit CAHPS PCMH data to NCQA Practices must use an NCQA-certified survey vendor to ensure a standardized method of data collection and reporting Practices earning distinction must be Recognized as PPC-PCMH or PCMH 2011 and will be listed in NCQA s directories as having distinction. Updated 9/24/13 18
PCMH 6C: Implement Continuous Quality Improvement The practice uses an ongoing quality improvement process to: Patient-Centered Medical Home (PCMH) 2011 There are two data submission periods per year. The first is in April; the second is in September. Either an adult or child CAHPS PCMH submission may be submitted towards Distinction. A practice need not submit both an adult and child survey for Distinction. Distinction is effective for one year after NCQA receives the practice's data. Practices must submit data annually (through a certified survey vendor) to maintain Distinction. Practices have the option of submitting data during both data submission periods. Practices must order and complete an NCQA CAHPS PCMH application that includes an agreement to have data submitted to NCQA. 8. Practice sites must use the CAHPS PCMH Survey to meet. CAHPS CG does not meet the requirement for. The use of the CAHPS PCMPH Survey is required to meet and as stated above to receive PCMH Distinction in Patient Experience Reporting. 8. Can we use Consumer Assessment of Healthcare Providers and Systems Clinician & Group (CAHPS CG)? 9. Can practices that have not applied for PCMH Recognition receive Distinction in Patient Experience Reporting? What is required to meet this factor? Factors 1-3 Can a practice state that the performance goal is to improve performance? 9. A non-recognized practice may submit data to NCQA following the requirements posted on NCQA s website. Practices without PCMH Recognition may still submit CAHPS PCMH results, but earning Distinction requires PCMH Recognition. The practice may have a suggestion box in the waiting room or host focus groups or conduct individual patient interviews, as a few examples of qualitative feedback. Free text questions on a practice s patient experience survey or patient comments will not suffice as a method of collecting qualitative feedback from patients/families. Factors 1-3 No, the performance goal must be quantified, e.g., stating a specific performance level that the practice is trying to achieve. 1. Set goals and act to improve performance on at least three measures from Element A 2. Set goals and act to improve performance on at least one measure from Element B 3. Set goals and address at least one identified disparity in care or service for vulnerable populations 4. Involve patients/families in quality improvement teams or on the practice s advisory council. PCMH 6D: Demonstrate Continuous Quality Improvement The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by: What is required in assessing the impact of improvement actions? Analysis requires a comparison of results over time and to evaluate what is driving the change. It may be qualitative or quantitative but the practice must look at the goals, action to improve and previous or baseline results. Updated 9/24/13 19
1. Tracking results over time 2. Assessing the effect of its actions 3. Achieving improved performance on one measure 4. Achieving improved performance on a second measure PCMH 6 E: Report Performance The practice shares performance data from Element A and Element B: 1. Within the practice, results by individual clinician 2. Within the practice, results across the practice 3. Outside the practice to patients or publicly, results across the practice or by clinician. PCMH 6F: Report Data Externally The practice electronically reports: 1. Ambulatory clinical quality measures to CMS or states 2. Ambulatory clinical quality measures to other external entities 3. Data to immunization registries or systems 4. Syndromic surveillance data to public health agencies. PCMH 6G: Use Certified EHR Technology This element is for your practice site Meaningful Use report only and will NOT be scored for your PCMH Recognition decision. To meet the federal Core and Menu Meaningful Use requirements: 1. The practice uses an EHR system (or modules) Factors 3-4 When re-measuring to show improvement, what is an acceptable period of time between the initial measurement and the follow-up measurement period? What happens if the practice does not do a patient survey and thus does not have data from 6B? Factors 1-4 Please explain what is required to meet each Factor. 1. Can PQRS be used to meet? 2. What documentation must a practice provide if CMS is not able to receive data transmission yet? Why include this element and these factors if it is not scored? Factors 3-4 NCQA does not specify the exact time period required for re-measurement. However, the time period must be long enough for the practice to implement a performance improvement plan and to assess the results. If the practice did not collect patient experience data for 6B, it is not required to show reporting from 6B for any of the factors in 6E. If the practice conducts patient experience surveys and shows reports in 6B, it is required to report the performance data from both 6A and 6B in order to get credit in 6E. Factors 1-4 : The practice provides reports of clinical quality measures. Demonstration of transmission is required when implemented by CMS or states. : The practice provides reports demonstrating electronic data transmission to other entities and public health agencies. Factors 3 and 4: The practice provides reports demonstrating electronic data submittal to immunization registries and public health agencies or a screen shot demonstrating the capability was tested. Instructions or a blank form are not acceptable. A data upload entry confirmation report is fine. 1. Yes, but only if measures are reported. Reporting from claims is not acceptable. 2. Certified EHRs can produce reports of clinical quality measures to which providers can attest to meet the documentation requirements for NCQA. Since these are Meaningful Use requirements, NCQA has included them to be able to provide the practice with a complete report of their Meaningful Use capability. Updated 9/24/13 20
that has been certified and issued a Certified HIT Products List (CHPL) Number(s) under the ONC (Office of the National Coordinator for Health Information Technology) HIT certification program 2. The practice attests to conducting a security risk analysis of its electronic health record (EHR) system (or modules) and implementing security updates as necessary and correcting identified security deficiencies Patient-Centered Medical Home (PCMH) 2011 Updated 9/24/13 21