||Minimum Documentation and Reporting Period
||PCMH 1: Patient Centered Access
|1A: Patient- Centered Appointment Access
|The practice has a written process and defined standards for providing access to appointments, and regularly assesses its performance on:
- Providing same-day appointments for routine and urgent care. (CRITICAL FACTOR)
- Providing routine and urgent -care appointments outside regular business hours.
- Providing alternative types of clinical encounters.
- Availability of appointments.
- Monitoring no-show rates.
- Acting on identified opportunities to improve access.
| (1-6) M
|1B: 24/7 Access to Clinical Advice
||The practice has a written process and defined standards for providing access to clinical advice and continuity of medical record information at all times, and regularly assesses its performance on:
- Providing continuity of medical record information for care and advice when office is closed.
- Providing timely clinical advice by telephone. (CRITICAL FACTOR)
- Providing timely clinical advice using a secure, interactive electronic system.
- Documenting clinical advice in patient records.
| (1) E
|1C: Electronic Access
||The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system.
- More than 50 percent of patients have timely access to their health information.
- The capability to view, download or transmit their health information to a third party.
- Clinical summaries are provided to patients/families/caregivers upon request.
- The capability to send a secure message.
- Patients have two-way communication with the practice.
- Patients can request appointments, prescription refills, referrals and test results.
| (1) E
||PCMH 2: Team-Based Care
| 2A: Continuity
||The practice provides continuity of care for patients/families by:
- Assisting patients/families to select a personal clinician and documenting the selection in practice records.
- Monitoring the percentage of patient visits with selected clinician or team.
- Having a process to orient new patients to the practice.
- Collaborating with the patient/family to develop/implement a written care plan for transitioning from pediatric care to adult care.
| (1) M
|2B: Medical Home Responsibilities
||The practice has a process for informing patients/families about the role of the medical home and gives patients/families materials that contain the following information.
- The practice is responsible for coordinating patient care across multiple settings.
- Instructions for obtaining care and clinical advice during office hours and when the office is closed.
- The practice functions most effectively as a medical home if patients provide a complete medical history and information about care obtained outside the practice.
- The care team provides access to evidence-based care, patient/family education and self-management support.
- The scope of services available within the practice including how behavioral health needs are addressed.
- The practice provides equal access to all of their patients regardless of source of payment.
- The practice gives uninsured patients information about obtaining coverage.
- Instructions on transferring records to the practice, including a point of contact at the practice.
| (1-8) M
|2C: Culturally and Linguistically Appropriate Services
||The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by:
- Assessing the diversity of its population.
- Assessing the language needs of its population.
- Providing interpretation or bilingual services to meet the language needs of its population.
- Providing printed materials in the languages of its population.
| (1-4) M
|2D: The Practice Team (MUST-PASS)
|| The practice uses a team to provide a range of patient-care services by:
- Defining roles for clinical and nonclinical team members.
- Identifying the team structure and the staff who lead and sustain team based care.
- Holding scheduled patient care team meetings or a structured communication process focused on individual patient care. (CRITICAL FACTOR)
- Using standing orders for services.
- Training and assigning members of the care team to coordinate care for individual patients.
- Training and assigning members of the care team to support patients/families/caregivers in self-management, self-efficacy and behavior change.
- Training and assigning members of the care team to manage the patient population.
- Holding scheduled team meetings to address practice functioning.
- Involving care team staff in the practice's performance evaluation and quality improvement activities.
- Involving patients/families/caregivers in quality improvement activities or on the practice's advisory council.
| (1-10) M
|| PCMH 3: Population Health Management
|3A: Patient Information
||The practice uses an electronic system to record patient information, including capturing information for factors 1-13 as structured (searchable) data for more than 80 percent of its patients:
- Date of birth.
- Preferred language.
- Telephone numbers.
- E-mail address.
- Occupation (NA for pediatric practices).
- Dates of previous clinical visits.
- Legal guardian/health care proxy.
- Primary caregiver.
- Presence of advance directives (NA for pediatric practices).
- Health insurance information.
- Name and contact information of other health care professionals involved in patient's care.
| (1-14) B
|3B: Clinical Data
||The practice uses an electronic system with the functionality in factors 6 and 7 and records the information in factors 1-5 and 8-11 as structured (searchable) data.
- An up-to-date problem list with current and active diagnoses for more than 80 percent of patients.
- Allergies, including medication allergies and adverse reactions, * for more than 80 percent of patients.
- Blood pressure, with the date of update, for more than 80 percent of patients 3 years or older.
- Height/length for more than 80 percent of patients.
- Weight for more than 80 percent of patients.
- System calculates and displays BMI.
- System plots and displays growth charts (length.height, weight and head circumference) and BMI percentile (0-20 years) (NA for adult practices).
- Status of tobacco use for patients 13 years and older for more than 80 percent of patients.
- List of prescription medications with date of updates for more than 80 percent of patients.
- More than 20 percent of patients have family history recorded as structured data.
- An electronic progress note that can be created, edited and signed by an eligible professional.
| (1-11) E
|3C: Comprehensive Health Assessment
|| To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment that includes:
- Age- and gender appropriate immunizations and screenings.
- Family/social/cultural characteristics.
- Communication needs.
- Medical history of patient and family.
- Advance care planning (NA for pediatric practices).
- Behaviors affecting health.
- Mental health/substance use history of patient and family.
- Developmental screening using a standardized tool (NA for practices with no pediatric patients).
- Depression screening for adults and adolescents using a standardized tool.
- Assessment of health literacy.
| (1-10) M
|3D: Use Data for Population Management
|| At least annually the practice proactively identifies populations of patients and reminds them, or their families/caregivers, of needed care based on patient information, clinical data, health assessments and evidence-based guidelines including:
- At least two different preventive care services.
- At least two different immunizations.
- At least three different chronic or acute care services.
- Patients not recently seen by the practice.
- Medication monitoring or alert.
| (1-4) B
|3E: Implement Evidence-Based Decision Support
||The practice implements clinical decision support (e.g., point-of-care reminders) following evidence-based guidelines for:
- A mental health or substance use disorder. (CRITICAL FACTOR)
- A chronic medical condition.
- An acute condition.
- A condition related to unhealthy behaviors.
- Well child or adult care.
- Overuse/appropriateness issues.
| (1-6) M
|| PCMH 4: Care Management and Support
|4A: Identify Patients for Care Management
|| The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of the following:
- Behavioral health conditions.
- High cost/high utilization.
- Poorly controlled or complex conditions.
- Social determinants of health.
- Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver.
- The practice monitors the percentage of the total patient population identified through its process and criteria. (CRITICAL FACTOR)
| (1-5) M
|4B: Care Planning and Self-Care Support (MUST PASS)
||The care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual care plan that includes the following features for at least 75 percent of the patients identified in Element A:
- Incorporates patient preferences and functional/lifestyle goals.
- Identifies treatment goals.
- Assesses and addresses potential barriers to meeting goals.
- Includes a self-management plan.
- Is provided in writing to the patient/family/caregiver.
| (1-5) M
|4C: Medication Management
||The practice has a process for managing medications, and systematically implements the process in the following ways:
- Reviews and reconciles medications for more than 50 percent of patients received from care transitions. (CRITICAL FACTOR)
- Reviews and reconciles medications with patients/families for more than 80 percent of care transitions.
- Provides information about new prescriptions to more than 80 percent of patients/families/caregivers.
- Assesses understanding of medications for more than 50 percent of patients/families/caregivers, and dates the assessment.
- Assesses response to medications and barriers to adherence for more than 50 percent of patients, and dates the assessment.
- Documents over-the-counter medications, herbal therapies and supplements for more than 50 percent of patients, and dates updates.
| (1-6) M
|4D: Use Electronic Prescribing
||The practice uses an electronic prescription system with the following capabilities:
- More than 50 percent of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies.
- Enters electronic medication orders in the medical record for more than 60 percent of medications.
- Performs patient-specific checks for drug-drug and drug-allergy interactions.
- Alerts prescribers to generic alternatives.
|4E: Support Self-Care and Shared Decision Making
||The practice has, and demonstrates use of, materials to support patients and families/caregivers in self-management and shared decision making. The practice:
- Uses an EHR to identify patient-specific education resources and provider them to more than 10 percent of patients.
- Provides educational materials and resources to patients.
- Provides self-management tools to record self-care results.
- Adopts shared decision making aids.
- Offers or refers patients to structured health education programs, such as group classes and peer support.
- Maintains a current resource list on five topics or key community service areas of importance to the patient population including services offered outside the practice and its affiliates.
- Assesses usefulness of identified community resources.
| (1) E
|| PCMH 5: Care Coordination and Care Transitions
|5A: Test Tracking and Follow-Up
||The practice has a documented process for and demonstrates that it:
- Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
- Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
- Flags abnormal lab results, bringing them to the attention of the clinician.
- Flags abnormal imaging results, bringing them to the attention of the clinician.
- Notifies patients/families of normal and abnormal lab and imaging test results.
- Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (NA for adults).
- More than 30 percent of laboratory orders are electronically recorded in the patient record.
- More than 30 percent of radiology orders are electronically recorded in the patient record.
- Incorporates clinical lab test results electronically into structured fields in the medical record.
- Makes scans and test that result in an image accessible electronically.
| (1-6) M
|5B: Referral Tracking and Follow-Up (MUST PASS)
- Considers available performance information on consultants/specialists when making referral recommendations.
- Maintains formal and informal agreements with a subset of specialists based on established criteria.
- Maintains agreements with behavioral healthcare providers.
- Integrates behavioral healthcare providers within the practice site.
- Gives the consultant or specialist the clinical question, the required timing and the type of referral.
- Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan.
- Has the capacity for electronic exchange of key clinical information and provides an electronic summary of care record to another provider for more than 10 percent of referrals.
- Tracks referrals until the consultant or specialist's report is available, flagging and following up on overdue reports. (CRITICAL FACTOR)
- Documents co-management arrangement in the patient's medical record.
- Asks patients/families about self-referrals and requesting reports from clinicians.
| (1-6) M
| 5C: Coordinate Care Transitions
- Proactively identifies patients with unplanned hospital admissions and emergency department visits.
- Shares clinical information with admitting hospitals and emergency departments.
- Consistently obtains patient discharge summaries from the hospital and other facilities.
- Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit.
- Exchanges patient information with the hospital during a patient's hospitalization.
- Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.
- Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another care facility for more than 10 percent of patient transitions of care.
| (1-6) M
||PCMH 6: Performance Management and Quality Improvement
|6A: Measure Clinical Quality Performance
||At least annually, the practice measures or receives data on:
- At least two immunization measures.
- At least two other preventive care measures.
- At least three chronic or acute care clinical measures.
- Performance data stratified for vulnerable populations (to assess disparities in care).
| (1-4) M
|6B: Measure Resource Use and Care Coordination
||At least annually, the practice measures or receives quantitative data on:
- At least two measures related to care coordination.
- At least two utilization measures affecting health care costs.
| (1-2) M
|6C: Measure Patient/Family Experience
|| At least annually, the practice obtains feedback from patients/families on their experiences with the practice and their care.
- The practice conducts a survey (using any instrument) to evaluate patient/family experiences on at least three of the following categories: Access. Communication. Coordination. Whole person care/self-management support.
- The practice uses the PCMH version of the CAHPS Clinician & Group Survey Tool.
- The practice obtains feedback on experiences of vulnerable patient groups.
- The practice obtains feedback from patients/families through qualitative means.
| (1-4) M
|6D: Implement Continuous Quality Improvement (MUST-PASS)
|| The practice uses an ongoing quality improvement process to:
- Set goals and analyze at least three clinical quality measures from Element A.
- Act to improve at least three clinical quality measures from Element A.
- Set goals and analyze at least one measure from Element B.
- Act to improve at least one measure from Element B.
- Set goals and analyze at least one patient experience measure from Element C.
- Act to improve at least one patient experience measure from Element C.
- Set goals and address at least one identified disparity in care/service for identified vulnerable populations.
| (1-7) M
|6E: Demonstrate Continuous Quality Improvement
||The practice demonstrates continuous quality improvement by:
- Measuring the effectiveness of the actions it takes to improve the measures selected in Element D.
- Achieving improved performance on at least two clinical quality measures.
- Achieving improved performance on one utilization or care coordination measure.
- Achieving improved performance on at least one patient experience measure.
| (1-4) M
|6F: Report Performance
||The practice produces performance data reports using measures from Elements A, B and C and shares:
- Individual clinician performance results with the practice.
- Practice-level performance results with the practice.
- Individual clinician or practice-level performance results publicly.
- Individual clinician or practice-level performance results with patients.
| (1-4) M
|6G: Use Certified EHR Technology
||The practice uses a certified EHR system.
- The practice uses an EHR system (or modules) that has been certified and issued a CMS certification ID.
- The practice conducts a security risk analysis of its EHR system (or modules), implements security updates as necessary and corrects identified security deficiencies.
- The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
- The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
- The practice demonstrates the capability to identify and report specific cases to a specialized registry (other than a cancer registry) electronically.
- The practice reports clinical quality measures to Medicare or Medicaid agency, as required for Meaningful Use.
- The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically.
- The practice has access to a health information exchange.
- The practice has bidirectional exchange with a health information exchange.
- The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10 percent of patients/families/caregivers about needed preventive/follow-up care.
| (1-2) E
||M = Accounts for possible 74.25 points and 5 Must-Pass Elements
B = Accounts for possible 8.75 points and 1 Must-Pass Element
I = Accounts for possible 3.62 points and 1 Must-Pass Element
E = Accounts for possible 9.37 points
A = Accounts for possible 2.25 points and 1 Must-Pass Element