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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.
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.
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.
NCQA does not prescribe a frequency; practices determine the time frame for conducting and updating patient health assessments according to a protocol that suits their patient population, aligns with evidence-based guidelines and allows for meaningful evaluation of data.
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.
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.
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.
Practices could use a variety of methods to collect language needs information on a large patient population. They may collect data from all patients and their families to create a report showing language needs or obtain data from an external source (e.g., data about the local community or its patient population).Â
Patients who do not speak English and patients from racial/ethnic minority groups may be less inclined to provide this information. Care should be taken to request the information using methods that respect multi-cultural differences.Â
Resource: NCQA’s 2010 Multicultural Health Care Standards (Abbreviated) E-Pub: http://store.ncqa.org/index.php/2010-mhc-standards-and-guidelines-electronic-pub.html Â
Yes. Use of PHQ-2/PHQ-9 meets the requirement if practices demonstrate its use in monitoring depression treatment and provide an example of the tool’s implementation in clinical care and decision making at the point of care. The intent of KM 20 A is to implement clinical decision support during treatment, not for screening or diagnosis of a mental health condition. Practices that use an evidence-based tool built into the EHR or as part of a workflow in accordance with clinical guidelines can meet the requirements if they demonstrate the guideline and an example of the guidelines implementation (i.e., the tool’s use).
Yes. This factor requires a documented process for handling referrals made by outside organizations (e.g., insurers, health system, ACO, other providers), practice staff or patient/ family/caregiver for patients that might need additional care management support; an ED is an outside organization.
Note: A report or patient list of referrals is not required for this factor.
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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:
