FAQ Directory

Social determinants of health are conditions in the environment that affect a wide range of health, functioning and quality-of-life outcomes and risks and include:

• Availability of resources to meet daily needs.
• Access to educational, economic and job opportunities.
• Public safety, social support.
• Social norms and attitudes.
• Exposure to crime, violence and social disorder.
• Socioeconomic conditions.
• Residential segregation.

Source: Healthy People 2020: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health.
 

PCMH 2017

Although “older adult patients” is an acceptable criterion for social determinants, it should be based on patients’ access to care or needs due to their social situation (e.g., living alone, not being able to drive to an appointment, food insecurity). Because social aspects associated with age may not apply to all patients over 65, Medicare enrollment alone may not be the best indicator.
Remember that patients identified in CM 01 are those who may benefit from care management and for whom a care plan is expected in the criteria outlined in Competency B. If the population is large because it includes all Medicare patients, the practice may want to reexamine the criteria to ensure that appropriate patients are identified.
 

PCMH 2017

Care planning supports patients identified for care management in CM 01 in managing their care to achieve target goals. Advance care planning (KM 02 I) is the care planning process with an end of life focus to address patient care when they cannot speak for themselves or are at the end of life.
 

PCMH 2017

No. Using only this age group does not meet the requirements. Identification of poorly controlled or complex patients can include older patients (e.g., >65 years) who also meet other high-risk criteria such as co-morbid conditions, frequent hospitalizations, mental health problems or frailty.

PCMH 2017

A care plan is based on the acute, chronic and preventive care needs of a patient and can include patient preferences and goals; treatment goals and status; assessment of barriers and strategies to address them; current problems and medications; allergies; and a self-care plan. This criterion requires practices to document a patient-centered view of the care plan and share the plan with the patient. A care plan does not need to be re-created at each visit but must be reviewed and updated as needed.

PCMH 2017

Yes. This factor requires a documented process for handling referrals made by outside organizations (e.g., insurers, health system, ACO, other providers), practice staff or patient/ family/caregiver for patients that might need additional care management support; an ED is an outside organization.
Note: A report or patient list of referrals is not required for this factor.
 

PCMH 2017

Practices are expected to show both availability (i.e., open appointment slots at the beginning of the day) and use of same-day appointments for a period of five consecutive days. Practices should also monitor the availability of same-day appointments against their documented process. Practices may use utilization of same-day appointment access as an indication of patient need.

PCMH 2017

Yes. Practices may use nonphysician members of the clinical care team, such as nurse practitioners or physician assistants (PA) who have their own panel of patients, for same-day appointments. There is no requirement for all clinicians to have same-day appointment slots available every day.

PCMH 2017

The practice should set its own goal for continuity of patient visits with their selected primary care provider or care team and then monitor that percentage to evaluate its performance. The practice should set goals such as by percentage, number of visits, etc. for the frequency patients should be seeing their selected provider and then monitor to see how frequent they are meeting their goal. The practice should provide its report including the rate of visits for patients with their provider including the goal established.
 

PCMH 2017

No. NCQA does not prescribe a percentage, nor does it expect patients to be seen by their selected primary care clinician for a specific percentage of visits.
 

PCMH 2017

Residency clinics should give patients the option to choose a care team that is under the direction of a staff or supervising physician. The personal clinician would not be a resident because the resident will no longer be associated with the clinic when their residency ends.
 

PCMH 2017

Documentation may be a screen shot demonstrating system capability. This could be multiple screenshots (one of the Web portal page and screenshots for each item) or one screenshot showing evidence of multiple capabilities required (requesting medication refills, appointments and requesting a referral or test) on an active website. Practices are also encouraged to demonstrate these capabilities with their evaluator during their virtual check-in.

PCMH 2017