Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.
KM 20 G requires evidence-based guidelines on appropriate use of services, which could include a prompt at the point of care to consider appropriateness of laboratory test ordering, avoidance of MRI as a first-line diagnostic test for back pain, appropriateness of antibiotics use, or appropriateness of specific referrals.
NCQA encourages practices to look at ABIM’s Choosing Wisely website for more information on overuse/appropriateness (www.choosingwisely.org).
PCMH 2017
Measures of care coordination address communication regarding patient referrals and care transitions.
For example, a practice refers a patient to another provider or a community resource. A care coordination measure might assess whether the referral was completed (i.e., the practice receives the referral report, follows up with the resource or patient to assess use or patient experience).
PCMH 2017
The intent of KM 03 is for the practice to implement universal screening for depression based on guidelines, so all adult and adolescent patients must be included. The practice should have a process to routinely screen patients and the frequency at which the screening is conducted should be based on evidence-based guidelines. The documented process should also include what follow-up occurs for positive screens.
PCMH 2017
Use of flow sheets, demonstration of EHR prompts or other evidence of guideline implementation with which the provider is alerted when a specific service or action is needed at the point of care, based on evidence-based guidelines, would meet the intent of KM 20. In addition to the evidence, practices must also provide information on the condition addressed by the clinical decision support and the source of the evidence-based guideline on which the clinical decision support is based.
Flow charts, copies of guidelines or empty templates do not demonstrate implementation of clinical decision support. These items show the guideline, but do not demonstrate its use at the point of care
PCMH 2017
No. While advance care planning could include a completed advance directive, it’s not required to meet KM 02. The practice must demonstrate that it documents results of advance care planning discussions with patients to meet this requirement. If a practice has an advance directive on file and documented in the patient medical record, that would also meet the intent.
PCMH 2017
CM 02 requires practices to create a process using criteria defined in CM 01 to identify patients for care management. The practice may use any method to identify these patients. For CM 02, practices need only provide a report showing the percentage of patients calculated from the number of patients identified using the defined criteria (numerator) in comparison to the entire patient population (denominator).
Note: Practices select at least three categories (CM 01) to define the subset of the patient population for care management for CM 02, and identify a population for care management (at least 30 patients) so they can report the criteria outlined in Competency B. Patients across the categories identified in CM 01 should be represented in the population identified for CM 02.
PCMH 2017
Practices must collect and document information on what may influence a patient’s overall safety, risk factors, health and well-being. The practice should consider all potential social determinants of health when collecting information from patients; however, practices are not required to have a complete list of every possible social determinant of health assessed for every patient. The purpose of this requirement is to collect information on areas that may be influencing/affecting a patient's health and well-being, many of which could be observed by the clinician/care team. Each practice is unique and there may be social determinants of health that are more common for their patient population as compared to others. Therefore, the practice may want to consider identifying common areas and develop standard questions to ask patients. However, the practice should not limit the assessment to just the most common areas or fields provided in their EHRs, to ensure all relevant information is documented in the patient's medical record.
PCMH 2017
For social functioning, NCQA is looking for the practice to assess and document an individual's ability to interact with others, to maintain relationships with friends or perform work. Several scales for the evaluation of social functioning are available (e.g., SFQ, SASS, GAF); however, NCQA does not require practices to utilize a standardized evaluation tool. If the practice does not elect to implement a specific assessment tool, it may consider developing its own set of questions based on its patient population. There may be some aspects of social functioning that the care team can determine by observation.
PCMH 2017
Yes. A comprehensive health assessment should be conducted for all patients and described in a documented process so the practice has relevant and documented information about patients' physical health and social and behavioral influences. That information is then utilized to provide appropriate services, interventions and resources to the patient population.
PCMH 2017
Practices should provide a report that demonstrates they update patient problem lists based on visits, transfer of information from other providers or information from the patient. As patient problem lists are expected to be updated at least annually, practices will want to monitor their rate on a periodic basis. Practices define the reporting period and frequency that allows meaningful evaluation of data.
PCMH 2017
Adult practices may identify lists of patients needing screenings (e.g., mammograms, colorectal screenings), check-up visits, annual lab testing or well-woman visits.
Preventive measures must encompass a practice’s entire appropriate population (not only patients with chronic conditions [KM 12 C]). The intent of reminding patients of preventive services is for practices to use their systems to identify specific groups of patients in need of services and to improve the quality of care for all patients in the practice.
PCMH 2017
