FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.29.2018 CC 08 What is an example of an informal agreement?

An informal agreement could be a few sentences in a referral form, e-mail or other method of communication containing expectations for the specialist, including, but not limited to, the time frame for reporting to the primary care physician and specifying lab or test results that should be included in the report. This information is essential to clarify the relationship between the primary care provider and specialist.
 

PCMH 2017

5.29.2018 CM 04 Does a clinical summary meet the requirement for a “plan of care”?

If the clinical summary also includes the details of the patient’s care plan (i.e., information outlined in the criterion guidance), then it would meet the requirement. A clinical summary alone that does not include the patient’s care plan information would not meet the requirement.

PCMH 2017

5.29.2018 CC 01 What is the minimal information required to meet the requirements of the laboratory and radiology items outlined in CC 01?

There is no minimum data requirement. To meet this core requirement, practices must meet all six items outlined in CC 01. Practices must consider how best to demonstrate their process for each item to meet the intent as described in the guidance section of this criterion. 

PCMH 2017

5.29.2018 CM 05 May practices make the individualized care plan available via patient portal, or are they required to provide the document in writing?

Although the care plan can be made available via the patient portal, it is essential that all patients have access to the document. If patients are not registered for the portal, they will not have access. In those cases, practices should use an alternative method to provide the written care plan to patients to ensure that all patients have access after an appointment. Please note practices must document that the care plan is provided to the patient in the patient’s medical record.
 

PCMH 2017

5.29.2018 QI 04B May practices use the “comments” section in the patient experience survey to meet this requirement?

No. Comment sections or “free text” questions on a patient experience survey do not meet the requirement as a method of collecting qualitative feedback from patients and their families.

PCMH 2017

5.29.2018 CM 07 Are practices required to document that they assess and address patient barriers to meeting treatment goals?

Yes. Practices must assess whether there are barriers to meeting goals and should address any identified barriers. Both components must be listed in the medical record in order to select “Yes” in the Record Review Workbook. If the practice assesses potential barriers and none are identified, the practice may answer “Yes.”
Note: Practices must provide an example of how they meet each criterion and complete the Record Review Workbook. Examples are not required if a practice provides a report as evidence.
 

PCMH 2017

5.29.2018 QI 12 How do practices assess the effectiveness of improvement actions?

Assessing effectiveness of improvement actions includes remeasurement to compare results over time and evaluation of what is driving change. Results may be quantitative (numerical data that demonstrate performance and can be compared to benchmarks) or qualitative (conceptual data that describe why performance is high or low), but practices must look at the goals set, actions taken to improve and previous or baseline results.

PCMH 2017

5.29.2018 CC 04C Are practices required to track every referral?

No. Practices must track important referrals, such as those made for high-risk patients.
 

PCMH 2017

5.29.2018 QI 12 When remeasuring to show improvement, what is an acceptable period of time between the initial measurement and the follow-up measurement period?

NCQA does not specify a time period required for remeasurement, but it must be long enough for the practice to implement a performance improvement plan and to assess results.

PCMH 2017

5.29.2018 CC 04C May practices use a “tickler file” for this item within CC 04?

No. The tracking system needs to include a record of both the order and receipt of results. A tickler system includes a copy of the order and is removed when results are received; it does not meet the requirement of the CC 04C because it does not maintain a record of receiving results.
 

PCMH 2017

5.29.2018 QI 06 Does the CAHPS PCMH Survey meet both QI 04 and QI 06?

The CAHPS PCMH Survey meets the requirement for QI 06 but only partially meets QI 04. The CAHPS PCMH Survey only meets the quantitative data requirement (QI 04A) for this criterion.  
 

Note: No modifications to the survey questions or length may be made. 

PCMH 2017

5.29.2018 CC 12 How do practices document co-management arrangements?

The practice must demonstrate at least three examples demonstrating co-management arrangements, such as de-identified referral forms that include the arrangements or sections of the medical record specifying the clinician responsible for each component of care. For example, for a diabetic patient who is referred to a medical oncologist, the arrangement would identify which clinician manages the diabetes and which clinician manages the side-effects of the oncology treatment and their expectation for timely sharing of patient information.
 

PCMH 2017