FAQ Directory: Patient-Centered Medical Home (PCMH)

No, neither secure, electronic fax noR secure email would meet the intent of CM 09. For CM 09, the practice must demonstrate its capability to make their patient's care plans available securely to other care settings, such as hospitals, specialists, or other care facilities that could be managing patient care. This availability should be at the time the patient is seen, including after hours, and as such should not involve reaching out to the practice for the information to be sent. The way in which this care plan is shared may vary and NCQA is not prescriptive, but examples include sharing care plans via shared medical records, HIEs or other shared systems that enable staff from different care settings to view the patient's care plan for continuity and optimal care coordination while the patient receives care from multiple settings.
 

PCMH 2017

For care coordination, the intent of QI 02A is to evaluate the communication/coordination that occurs between providers or providers and patients, so it's generally looking at closing the loop on care coordination tasks/processes. Some examples for care coordination may include but are not limited to:
 
– Reduced % of patients seeing multiple providers (3 or more)
– Medication reconciliation after care transition (MU)
– Follow up with patients or providers to ensure ordered lab or imaging tests were completed
– Follow up with patients following receipt of abnormal test results
– Outreach to patients not recently seen that result in an appointment
– Follow-up phone calls to check on the patient after an ER visit (or hospitalization)
– # patient calls received after hours by the call center were reconciled in the patient record and addressed by the care team the next business day
– Following up on pediatric visits to after-hours care
– Number of referrals sent
– % of patients who had a positive TB screen who had a FU Chest x-ray
– % of patients who had a positive GC/Chlamydia who were treated with antibiotics
 
 
The intent of QI 02B is for practices to use measures to help them understand how efficiently they're providing care and judiciously using resources. Examples of measures affecting health care costs may include but are not limited to:
 
– Total cost per patient
– Medical cost per medical visit
– # of medications prescribed
– Use of high cost medications
– Use of imaging for low back pain
– Redundant imaging or lab tests
– Emergency department utilization
– Hospital readmission rates
– Use of generic versus brand name medication
– # of Specialist referrals
– # of patients who went to urgent care during open office hours
– # of referrals/ED visits for needs that could be addressed in the office
– Appropriate testing for children with pharyngitis
– Appropriate treatment for children with URI
 

PCMH 2017

Participating in an HIE can help practices demonstrate PCMH criteria; however, connection alone does not demonstrate the evidence needed to meet the following criteria. Practices must demonstrate how they use the HIE to meet each criterion. Utilization of an HIE could help meet the following criteria:
 

PCMH 2017

SDOH Roadmap
https://healthleadsusa.org/resource-library/roadmap/

PCMH 2017

AR-TC 2 (Employee Experience Feedback) does not align to a PCMH criteria. AR-TC 2 was included as an option for practices to demonstrate whether they evaluate concepts related to team-based care in their employee surveys. It is not a required requirement in Annual Reporting.

PCMH 2017

In BH 15 (Core), the practice monitors either a mental health condition OR a substance use disorder. BH 16 is elective because it raises the bar by evaluating whether practices monitor both a mental health condition AND a substance use disorder. 

PCMH 2017

No, a single clinician practice may simply attest to having a single clinician. This can be done using the text box option of Q-PASS to receive credit for these criteria.

PCMH 2017

Elective criterion KM 07 goes beyond providing the percentage of patients with social determinants of health documented in the medical record; the report should include the breakdown by social determinant(s) so the practice understands which social determinants impact their patients to better implement appropriate care interventions. The intent of elective criterion is for the practice to show how it monitors social determinants of health at the population level for its patient population and also how it uses that data to address and assist in overcoming those social determinants of health. Reports may be generated from data collected in KM 02 G.

PCMH 2017

A practice with integrated behavioral health may provide its documented process and evidence of implementation. For evidence of implementation, the practice might demonstrate the practice's internal process for entering patient treatment notes, referral guidance and medication management within its system and how the integrated BH provider updates the PCP about the patient's progress. The documented process may also include how the practice facilitates transition to BH, such as through warm handoffs.

PCMH 2017

No, the redesigned PCMH process enables practices to enroll and transform into a PCMH over the course of a 12 month period. If the documented process has been implemented for a sufficient amount of time for the practice to demonstrate the needed evidence to meet criteria, the practice may submit it for review.

PCMH 2017

The expectation is that these facets of the care plan should be happening routinely. NCQA has not set a specific threshold, however if the practice is reporting less than 75% the evaluator may question whether the practice has truly implemented the criteria as part of their care plan routine.

PCMH 2017

If the practice offers to print the care plan and the patient declines, the practice may count the patient as a 'Yes'.

PCMH 2017