FAQ Directory: Patient-Centered Medical Home (PCMH)

The OMB is requiring “Middle Eastern or North African” for the race/ethnicity combination list. If you do not have “Middle Eastern or North African” as a race only option (if you are collecting race and ethnicity separately), it is ok.

We are instructing practices to work with their vendor to include the “Middle Eastern or North African” option to the combination race/ethnicity category so practices can transition to the OMB race/ethnicity combo for future collection.
 

PCMH

Yes. Adult practices can submit one of these as a custom immunization measure. Since neither of these have 2024 specifications in the eCQI Resource Center, you will need to enter the  numerator/denominator definitions along with your data.
 

PCMH

PCMH 2017

No, unless otherwise stated in the specifications, quality measures do not have thresholds that must be met.  

With that said, CMS 68 is similar to KM-15 (core): Maintaining an up-to-date list of medications for more than 80% of patients. Both sets of data require the same action of updating the medication list. However, they differ in that CMS 68 is for patients age 18+ and must be captured at every visit, whereas KM-15 is for all patients at any given time. It is unlikely that there would be a large variance between CMS 68 and KM-15. NCQA requests a note be added in QPASS if CMS 68 differs greatly from KM-15's 80% requirement. This is to provide context to the Review Oversight Committee to better understand your practice and environment. 

If your practice is in Annual Reporting, practices attest that they are in compliance with all core criteria and could provide evidence that they are meeting the more than 80% requirement of KM-15. 

PCMH 2017

The request for provider sign-off stems from the ability to verify work has been reviewed by the eligible clinician, and not solely managed by another role within the organization—or externally.

An eligible provider must be able to provide evidence of their involvement in Care Management efforts. They should not be submitting care management efforts they have not directly reviewed. That said, we suggest provider’s sign-off on care plans to indicate that they have reviewed the care plans they are counting towards their CM efforts. 

If there is a systematic limitation–meaning an electronic system does not allow the provider to electronically sign-off on the care plan–an acceptable workaround would be to provide a relevant office visit note(s), a telephone communication note(s), etc. where the provider has documented that the care plan was reviewed, discussed, updated, etc. with the patient. 

Evidence provided should exemplify that the eligible clinician has had direct oversight in care management efforts for the patient. Care planning efforts may be facilitated by other parties within the practice, but the eligible clinician must be an involved participant in the care management efforts included in their CM reporting.

PCMH 2017

The expectation is that diversity data is collected from all patients in the practice. An overwhelming majority of the practice’s population should have diversity data on file. If this is not the case, the practice should annotate an implementation plan in the notes section of Q-PASS. This plan should include an expected timeline for improved performance.

Please note that diversity data should be collected directly from the patient/family/caregiver. Please refer to the Standards and Guidelines for acceptable response options for each aspect of diversity.
 

PCMH 2017

For AR-CM 1 (AR 2024), “total population” is defined as unique patients seen by the practice in the prior 12 months. The intent of this attestation is to provide a point of reference for the ratio of care managed patients to your practice-site’s total patient population.
 

PCMH 2017

The document should not simply be a hardcoded paper that auto-populates structured fields from the EHR into the document. It should contain language showing that the patient provided input and understands the plan. NCQA is not prescriptive on specific verbiage that must be in the care plan. 

The intent of CM 04 is to give the patient ownership and the power to improve their health outcomes. Engaging the patient in the development of their care plan can result in greater success and adherence to treatment goals.  

PCMH 2017

This means that the information is not all medical jargon. So instead of the care plan stating, “1 PO BID”, the practice may say “take one by mouth two times a day.” Instead of hardcoded complex diagnosis names and codes, write the diagnosis in common language. For example, instead of only providing the diagnosis of “dyspnea,” use “shortness of breath.”  

The intent is to ensure that the patient understands his/her condition(s), goals, and plans to follow to improve their health.  

PCMH 2017

An example of expected outcome/prognosis is typically clinically based. Expected outcome/prognosis is what the expected outcome of complying with the care plan would be. You can think about it as if a patient follows all instructions of the care plan what you are expecting to happen (e.g., their A1C/BMI/stroke risk etc. will decrease). Generally, we see practices differentiate treatment outcome/prognosis as a more clinical metric, for instance lowering A1C by 2 points etc.  

Treatment goals are more lifestyle choices or outcomes for the patient, such as eating more vegetables or getting enough exercise to be able to walk around the block etc.  

All of these elements are incorporated into the care plan: a problem list, expected outcome/prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed.  

PCMH 2017

There has been an update to the PCMH 2023 annual reporting requirements. AR TC 1 ( Staff Involvement in Quality Improvement) and AR CC 1 ( Hospital and ED Coordination) will now require additional documentation to demonstrate practices are meeting requirements. NCQA is requesting a documented process and evidence of implementation in addition to attestation for this criteria. All practices will have the ability to upload necessary documentation in Q-PASS by the end August. Until then, your RP manager may reach out to request additional documents.
 

PCMH 2017

PCMH 2017