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

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

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

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

Yes. NCQA accepts telepsychiatry visits as an alternative clinical encounter if the behavioral healthcare practitioner is at least partially integrated with the practice site (i.e., sharing at least partial access to the same systems and patient records).

PCMH 2017

Yes. Practices may refer patients to associated urgent care sites or facilities (i.e., facilities with which the practice has a relationship or an agreement to work together) to meet AC 03, but must provide a documented process demonstrating how patients are referred to facilities for scheduled routine and urgent appointments. The facility must have access to patient medical records outside regular business hours.

PCMH 2017

Yes, members of the clinical staff (including clinicians and nurses) providing clinical care to patients (based on pertinent licensing laws) may be scheduled for an alternative appointment with a patient. These appointments are in place of those scheduled in the physical office and provided by telephone or other technology supported mechanisms. Visits with social workers, nutritionists, educators or pharmacists alone without an accompanying staff member administering clinical care would not meet the intent of the criterion.

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, this meets the requirement if the telehealth provider is a clinician, provides a scheduled appointment and has access to practice systems and the patient’s medical record.

PCMH 2017

Yes. The requirement is met if the response time is documented when a patient submits an electronic request for clinical advice and the practice communicates to patients that an on-call provider is available to address urgent issues by telephone after hours. Practices must have a documented process for addressing electronic advice and telephone advice; for this criterion, practices may submit a report tracking response times to electronic requests for at least seven days during operating hours and after hours.
 

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

No. Practices must 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 2017