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.
 

This applies to the following Programs and Years:

Practices use the patients identified in CM 02 as the denominator for criteria in Competency B. To earn credit for each criterion, practices must document the required information for at least 75 percent of those patients. For evidence, practices must either complete the Record Review Workbook or submit a report.

• Practices that submit the Record Review Workbook must provide an example of each criterion, demonstrating how providing information is documented in the medical record.
• Practices that submit a report must provide a report with at least three months of recent data showing the number of patients who had the criterion-specific information documented in their medical record (numerator) out of the total number of patients identified in CM 02 (denominator).

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years:

No. Practices with a patient sample that includes both pediatric and adult patients for reporting provide at least one pediatric example and at least one adult example for the criteria outlined in Competency B, but are not required to provide a pediatric example and an adult example for each criterion.

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

Patients, caregivers or family members are not likely to request care management services unless they are health care professionals; however, caregivers or family members may acknowledge the patient’s inability to self-manage care or to follow clinician instructions, or a patient may acknowledge his or her own inability to manage care, and that might lead a practice to consider the patient for care management services.

For example, children of a widower who relied on his spouse to help him manage a chronic condition might alert the practice that their father cannot manage his care and that they are not in a position to provide help.

This applies to the following Programs and Years:

No. Tobacco use is an unhealthy behavior and is not considered a behavioral health condition. Practices need to identify behavioral health-related criteria pertinent to their specific patient population, which could include other (non-tobacco-related) substance use treatment, a behavioral health diagnosis, a positive screening result from a standardized behavioral health screener or psychiatric hospitalizations.
 

This applies to the following Programs and Years:

CM 01 focuses on the practice’s established criteria and systematic process for identifying patients in need of care management. Comprehensive risk stratification in CM 03 requires a more complex identification process than that of CM 01. CM 03 goes beyond simply establishing criteria and provides elective credit to practices that are using a risk assessment process to identify patients for care management, leveraging clinical data about the patients; it is about stratifying patients using all the factors that put the patient at higher risk and in need of assistance in managing their health. If a practice meets CM 03, it will automatically meet CM 01.
 

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years:

The intent of AC 01 is to assess the access needs and preferences of the practice’s patient population. To identify the best way to obtain this information, practices may need to review how they are currently collecting patient feedback on access needs. For example, a patient survey may ask patients if they are able to get an appointment when needed; however, that question doesn't tell you when patients want to access the practice. The practice may be offering access when the majority of patients don't or aren't able to utilize it.
Practices should collect and assess the feedback from patients to see if there's a need to adjust the access provided to patients. Some questions to   consider include:

1. What data are you already collecting on patient access (e.g. surveys, use of appointments)? Is it current and does it cover the whole patient population?
2. How often do you need to assess the access needs of your patients?
3. What variables may impact changes in the use of appointment types?
4. If using patient satisfaction surveys, how many patients are actually responding? If the response rate is low, is there another mode of collecting feedback to get more input.
5. Do the questions on your survey ask patients directly about their access needs or preferences?

This applies to the following Programs and Years:

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.
 

This applies to the following Programs and Years: