FAQ Directory: Patient-Centered Medical Home (PCMH)

No, practices are not required to use an NCQA-Certified survey vendor.

PCMH 2017

No. Practices are not required to identify all patients admitted to the hospital or ED, but they must have a process for identifying patients admitted to facilities used most often by their population. In addition to a documented process, practices must also submit a log or report demonstrating that patients were identified.
 

PCMH 2017

Yes. Practices that use integrated systems must demonstrate how specialists are notified of a referral request and how the referral status will be tracked (including the specialist’s report). Even if the same EHR is used by both the primary care practitioner and the specialist, evidence must clearly demonstrate how the requirements are met within the system.
 

PCMH 2017

No. The evidence required for KM 02 does not require a report. The practice should outline how it collects and documents this information in its documented process. For evidence of implementation, the practice can demonstrate its process during the virtual check-in, which may include sharing where the information is documented in the patient record.

PCMH 2017

No. If a patient is considered an adult by the practice (typically 18 or older), the practice should have an advance care planning discussion with the patient, and the results of that discussion should be documented in the patient medical record.

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

The practice must demonstrate evidence (i.e., patient list/report and outreach materials) of a service reminder provided within the past year for 3 of the 4 categories/items within KM 12. After achieving Recognition, practices are expected to report on reminders on their Annual Report.

PCMH 2017

No. Although it may be duplicate information, practices cannot assume that the pharmacy provided the information to the patient. Communication and partnership with patients are critical functions of the patient-centered medical home, and practices must ensure that patients/families/caregivers understand why medication was prescribed and its benefits and potential harms to the patient. Additionally, patients might not review prescription information provided by a pharmacy, and information might not be tailored to the needs of the patient/family/caregiver.

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

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.

PCMH 2017

Preventive measures must encompass a practice’s entire population and not be limited to patients with chronic conditions

PCMH 2017

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.

PCMH 2017