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NCQA PCMH 2014 Standards, Elements and Factors

Documentation Guideline/Data Sources

Key:

  • DP = Documented Process describing policy or procedure  
  • Rate = Report numerator and denominator creating percent of use or rate, over 3 months, unless otherwise stated
  • RPT = Report of data or information, rate is a type of report
  • EM = Example, explanation or materials
  • RR = Record Review Workbook, represents records or files
  • QM = Quality Measurement and Improvement Worksheet

Notes:

  • Exchange means 2 way data exchange, provides means one way.
  • Exchange of data/communication is not required if systems are shared.
  • Report data may be shown in summary, may be from electronic system as screen shot.
  • Documentation may be combined to reduce document count. 

 

Description

Minimum Documentation and Reporting Period


PCMH 1: Patient Centered Access

 

1A: Patient-Centered Appointment Access

(MUST PASS)

The practice has a written process and defined standards for providing access to appointments, and regularly assesses its performance on:

  1. Providing same-day appointments for routine and urgent care. (CRITICAL FACTOR)
  2. Providing routine and urgent-care appointments outside regular business hours.
  3. Providing alternative types of clinical encounters.
  4. Availability of appointments.
  5. Monitoring no-show rates.
  6. Acting on identified opportunities to improve access.

 (1) DP and RPT 5 da

(2) DP or EM

(3) DP and RPT 30 da

(4) DP and RPT 5 da

(5) DP and RPT 30 da (inc. Rate)

(6) DP and RPT or QI worksheet

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:

  1. Providing continuity of medical record information for care and advice when office is closed.
  2. Providing timely clinical advice by telephone. (CRITICAL FACTOR)
  3. Providing timely clinical advice using a secure, interactive electronic system.
  4. Documenting clinical advice in patient records.

 (1) DP

 

(2) DP and RPT 7 da

(3) DP and RPT 7 da

(4) DP and 3 EM

1C: Electronic Access

The following information and services are provided to patients/families/ caregivers, as specified, through a secure electronic system.

  1. More than 50 percent of patients have timely access to their health information.
  2. The capability to view, download or transmit their health information to a third party.
  3. Clinical summaries are provided to patients/families/caregivers upon request.
  4. The capability to send a secure message.
  5. Patients have two-way communication with the practice.
  6. Patients can request appointments, prescription refills, referrals and test results.

 

(1)Rate

(2) EM or Rate

(3) EM or Rate

(4) EM or rate
(5) EM
(6) EM

 

 PCMH 2: Team-Based Care

 

2A: Continuity

The practice provides continuity of care for patients/families by:

  1. Assisting patients/families to select a personal clinician and documenting the selection in practice records.
  2. Monitoring the percentage of patient visits with selected clinician or team.
  3. Having a process to orient new patients to the practice.
  4. Collaborating with the patient/family to develop/implement a written care plan for transitioning from pediatric care to adult care.

 (1)DP and EM

 (2)RPT 5 da

(3)DP

(4)EM

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:

  1. The practice is responsible for coordinating patient care across multiple settings.
  2. Instructions for obtaining care and clinical advice during office hours and when the office is closed.
  3. The practice functions most effectively as a medical home if patients provide a complete medical history and information about care obtained outside the practice.
  4. The care team provides access to evidence-based care, patient/family education and self-management support.
  5. The scope of services available within the practice including how behavioral health needs are addressed.
  6. The practice provides equal access to all of their patients regardless of source of payment.
  7. The practice gives uninsured patients information about obtaining coverage.
  8. Instructions on transferring records to the practice, including a point of contact at the practice.

 

(1-8) DP and EM

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:

  1. Assessing the diversity of its population.
  2. Assessing the language needs of its population.
  3. Providing interpretation or bilingual services to meet the language needs of its population.
  4. Providing printed materials in the languages of its population.

 

 (1)RPT

(2)RPT

(3)EM or DP

(4)EM

2D: The Practice Team (MUST-PASS)

The practice uses a team to provide a range of patient care services by:

  1. Defining roles for clinical and nonclinical team members.
  2. Identifying the team structure and the staff who lead and sustain team based care.
  3. Holding scheduled patient care team meetings or a structured communication process focused on individual patient care. (CRITICAL FACTOR)
  4. Using standing orders for services.
  5. Training and assigning members of the care team to coordinate care for individual patients.
  6. Training and assigning members of the care team to support patients/families/caregivers in self-management, self-efficacy and behavior change.
  7. Training and assigning members of the care team to manage the patient population.
  8. Holding scheduled team meetings to address practice functioning.
  9. Involving care team staff in the practice’s performance evaluation and quality improvement activities.
  10. Involving patients/families/caregivers in quality improvement activities or on the practice’s advisory council.

(1)EM

(2) EM

(3) DP and 3 EM

(4) EM

 (5-7) 2 EM (description + training materials or schedule)

(8) 2 EM (description + example)

(9) DP

(10) DP or EM

 

 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:

  1. Date of birth.
  2. Sex.
  3. Race.
  4. Ethnicity.
  5. Preferred language.
  6. Telephone numbers.
  7. E-mail address.
  8. Occupation (NA for pediatric practices).
  9. Dates of previous clinical visits.
  10. Legal guardian/health care proxy.
  11. Primary caregiver.
  12. Presence of advance directives (NA for pediatric practices).
  13. Health insurance information.
  14. Name and contact information of other health care professionals involved in patient’s care.

 (1-13) Rate

 (14) DP and 3 EM

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.

  1. An up-to-date problem list with current and active diagnoses for more than 80 percent of patients.
  2. Allergies, including medication allergies and adverse reactions,* for more than 80 percent of patients.
  3. Blood pressure, with the date of update, for more than 80 percent of patients 3 years and older.
  4. Height/length for more than 80 percent of patients.
  5. Weight for more than 80 percent of patients.
  6. System calculates and displays BMI.
  7. System plots and displays growth charts (length/height, weight and head circumference) and BMI percentile (0-20 years) (NA for adult practices).
  8. Status of tobacco use for patients 13 years and older for more than 80 percent of patients.
  9. List of prescription medications with date of updates for more than 80 percent of patients.
  10. More than 20 percent of patients have family history recorded as structured data.
  11. An electronic progress note that can be created, edited and signed by an eligible professional.

 

 (1-5 and 8-10) Rate

 

(6, 7) EM

 

(11) Rate or EM

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:

  1. Age- and gender appropriate immunizations and screenings.
  2. Family/social//cultural characteristics.
  3. Communication needs.
  4. Medical history of patient and family.
  5. Advance care planning (NA for pediatric practices).
  6. Behaviors affecting health.
  7. Mental health/substance use history of patient and family.
  8. Developmental screening using a standardized tool (NA for practices with no pediatric patients).
  9. Depression screening for adults and adolescents using a standardized tool.
  10. Assessment of health literacy.

 

 

(1-10) Rate or RR + EM

 

and

 

(8, 9)  EM

(10) Rate or RR + EM or EM (demonstration of how health literacy is addressed at the practice)

3D: Use Data for Population Management (MUST-PASS)

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:

  1. At least two different preventive care services.
  2. At least two different immunizations.
  3. At least three different chronic or acute care services.
  4. Patients not recently seen by the practice.
  5. Medication monitoring or alert.

 

 (1-5) RPT (List) and EM for each service

3E: Implement Evidence-Based Decision Support

The practice implements clinical decision support+ (e.g., point-of-care reminders) following evidence-based guidelines for:

  1. A mental health or substance use disorder. (CRITICAL FACTOR)
  2. A chronic medical condition.
  3. An acute condition.
  4. A condition related to unhealthy behaviors.
  5. Well child or adult care.
  6. Overuse/appropriateness issues.

 (1-6) Condition, guideline source and EM

 

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:

  1. Behavioral health conditions.
  2. High cost/high utilization.
  3. Poorly controlled or complex conditions.
  4. Social determinants of health.
  5. Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver.
  6. The practice monitors the percentage of the total patient population identified through its process and criteria. (CRITICAL FACTOR)

 

 

(1-5) Criteria

 (6) Rate (Total Practice)

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:

  1. Incorporates patient preferences and functional/lifestyle goals.
  2. Identifies treatment goals.
  3. Assesses and addresses potential barriers to meeting goals.
  4. Includes a self-management plan.
  5. Is provided in writing to the patient/family/caregiver.

 (1-5) Rate or RR and EM

4C: Medication Management

The practice has a process for managing medications, and systematically implements the process in the following ways:

  1. Reviews and reconciles medications for more than 50 percent of patients received from care transitions. (CRITICAL FACTOR)
  2. Reviews and reconciles medications with patients/families for more than 80 percent of care transitions.
  3. Provides information about new prescriptions to more than 80 percent of patients/families/caregivers.
  4. Assesses understanding of medications for more than 50 percent of patients/families/caregivers, and dates the assessment.
  5. Assesses response to medications and barriers to adherence for more than 50 percent of patients, and dates the assessment.
  6. Documents over-the-counter medications, herbal therapies and supplements for more than 50 percent of patients, and dates updates.

 (1-6) Rate or RR and EM

4D: Use Electronic Prescribing

The practice uses an electronic prescription system with the following capabilities:

  1. More than 50 percent of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies.
  2. Enters electronic medication orders in the medical record for more than 60 percent of medications.
  3. Performs patient-specific checks for drug-drug and drug-allergy interactions.
  4. Alerts prescribers to generic alternatives.

 

(1) Rate and EM

 (2) Rate

 (3-4) EM

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:

  1. Uses an EHR to identify patient-specific education resources and provide them to more than 10 percent of patients.
  2. Provides educational materials and resources to patients.
  3. Provides self-management tools to record self-care results.
  4. Adopts shared decision making aids.
  5. Offers or refers patients to structured health education programs, such as group classes and peer support.
  6. 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.
  7. Assesses usefulness of identified community resources.

 

 (1) Rate

 (2-5) 3 EM

 (6-7) EM

 

 

 

 

 PCMH 5: Care Coordination and Care Transitions 


5A: Test Tracking and Follow-Up

The practice has a documented process for and demonstrates that it:

  1. Tracks lab tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
  2. Tracks imaging tests until results are available, flagging and following up on overdue results. (CRITICAL FACTOR)
  3. Flags abnormal lab results, bringing them to the attention of the clinician.
  4. Flags abnormal imaging results, bringing them to the attention of the clinician.
  5. Notifies patients/families of normal and abnormal lab and imaging test results.
  6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (NA for adults).
  7. More than 30 percent of laboratory orders are electronically recorded in the patient record.
  8. More than 30 percent of radiology orders are electronically recorded in the patient record.
  9. Incorporates clinical lab test results electronically into structured fields in the medical record.
  10. Makes scans and test that result in an image accessible electronically.

 

(1-6) DP and RPT or EM

(7-8) Rate

(9-10) Rate or EM

5B: Referral Tracking and Follow-Up (MUST-PASS)

The practice:

  1. Considers available performance information on consultants/specialists when making referral recommendations.
  2. Maintains formal and informal agreements with a subset of specialists based on established criteria.
  3. Maintains agreements with behavioral healthcare providers.
  4. Integrates behavioral healthcare providers within the practice site.
  5. Gives the consultant or specialist the clinical question, the required timing and the type of referral.
  6. Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan.
  7. 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.
  8. Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports. (CRITICAL FACTOR)
  9. Documents co-management arrangements in the patient’s medical record.
  10. Asks patients/families about self-referrals and requesting reports from clinicians.

(1-4) EM

(5, 6) DP and RPT or EM

(7) EM and Rate

(8) DP and RPT or EM

(9, 10) 3 EM

 

 

5C: Coordinate Care Transitions

The practice:

  1. Proactively identifies patients with unplanned hospital admissions and emergency department visits.
  2. Shares clinical information with admitting hospitals and emergency departments.
  3. Consistently obtains patient discharge summaries from the hospital and other facilities.
  4. Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit.
  5. Exchanges patient information with the hospital during a patient’s hospitalization.
  6. Obtains proper consent for release of information and has a process for secure exchange of information and for coordination of care with community partners.
  7. 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) DP and RPT

(2-4) DP and 3 EM

(5) DP and EM

(6) DP

(7) EM and Rate

 



 PCMH 6: Performance Management and Quality Improvement

 

6A: Measure Clinical Quality Performance

At least annually, the practice measures or receives data on:

  1. At least two immunization measures.
  2. At least two other preventive care measures.
  3. At least three chronic or acute care clinical measures.
  4. Performance data stratified for vulnerable populations (to assess disparities in care).

 

(1-4) RPT

6B: Measure Resource Use and Care Coordination

At least annually, the practice measures or receives quantitative data on:

  1. At least two measures related to care coordination.
  2. At least two utilization measures affecting health care costs.

 

(1-2) RPT

 

6C: Measure Patient/Family Experience

At least annually, the practice obtains feedback from patients/families on their experiences with the practice and their care.

  1. 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.
  2. The practice uses the PCMH version of the CAHPS Clinician & Group Survey Tool.
  3. The practice obtains feedback on experiences of vulnerable patient groups.
  4. The practice obtains feedback from patients/families through qualitative means.

 (1-4) RPT

6D: Implement Continuous Quality Improvement (MUST-PASS)

The practice uses an ongoing quality improvement process to:

  1. Set goals and analyze at least three clinical quality measures from Element A.
  2. Act to improve at least three clinical quality measures from Element A.
  3. Set goals and analyze at least one measure from Element B.
  4. Act to improve at least one measure from Element B.
  5. Set goals and analyze at least one patient experience measure from Element C.
  6. Act to improve at least one patient experience measure from Element C.
  7. Set goals and address at least one identified disparity in care/service for identified vulnerable populations.

 (1-7) RPT or QM

6E: Demonstrate Continuous Quality Improvement

The practice demonstrates continuous quality improvement by:

  1. Measuring the effectiveness of the actions it takes to improve the measures selected in Element D.
  2. Achieving improved performance on at least two clinical quality measures.
  3. Achieving improved performance on one utilization or care coordination measure.
  4. Achieving improved performance on at least one patient experience measure.

 (1-4) RPT or QM

6F: Report Performance

The practice produces performance data reports using measures from Elements A, B and C and shares:

  1. Individual clinician performance results with the practice.
  2. Practice-level performance results with the practice.
  3. Individual clinician or practice-level performance results publicly.
  4. Individual clinician or practice-level performance results with patients.

 (1, 2) RPT and EM

 (3, 4) EM

6G: Use Certified EHR Technology

The practice uses a certified EHR system.

  1. The practice uses an EHR system (or modules) that has been certified and issued a CMS certification ID.
  2. The practice conducts a security risk analysis of its EHR system (or modules), implements security updates as necessary and corrects identified security deficiencies
  3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically.
  4. The practice demonstrates the capability to identify and report cancer cases to a public health central cancer registry electronically.
  5. The practice demonstrates the capability to identify and report specific cases to a specialized registry (other than a cancer registry) electronically.
  6. The practice reports clinical quality measures to Medicare or Medicaid agency, as required for Meaningful Use.
  7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically.
  8. The practice has access to a health information exchange.
  9. The practice has bidirectional exchange with a health information exchange.
  10. 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.

 (1-10) Response only