FAQ Directory

By resource stewardship, we mean ensuring responsible use of resources while providing high quality, efficient, patient-centered primary care as it relates measures affecting health care costs and care coordination.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

No. Practices must ask about all medications prescribed to the patient and assess their efficacy, especially for patients identified in CM 01 as needing care management. Patients may have multiple comorbidities and medications, so it is crucial to evaluate their response and barriers to adherence for all medications prescribed to them.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

Practices must demonstrate:

* An example of the criterion documented in the patient record, and

* A completed developmental screening form. 

or

* A report, and

* A completed developmental screening form. 

This applies to the following Programs and Years:

CM 02 requires practices to create a process using criteria defined in CM 01 to identify patients for care management. The practice may use any method to identify these patients. For CM 02, practices need only provide a report showing the percentage of patients calculated from the number of patients identified using the defined criteria (numerator) in comparison to the entire patient population (denominator).
Note: Practices select at least three categories (CM 01) to define the subset of the patient population for care management for CM 02, and identify a population for care management (at least 30 patients) so they can report the criteria outlined in Competency B. Patients across the categories identified in CM 01 should be represented in the population identified for CM 02.
 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

No. Practices with a patient sample that includes both pediatric and adult patients for reporting provide at least one pediatric example and at least one adult example for the criteria outlined in Competency B, but are not required to provide a pediatric example and an adult example for each criterion.

This applies to the following Programs and Years:

Practices use the patients identified in CM 02 as the denominator for criteria in Competency B. To earn credit for each criterion, practices must document the required information for at least 75 percent of those patients. For evidence, practices must either complete the Record Review Workbook or submit a report.

• Practices that submit the Record Review Workbook must provide an example of each criterion, demonstrating how providing information is documented in the medical record.
• Practices that submit a report must provide a report with at least three months of recent data showing the number of patients who had the criterion-specific information documented in their medical record (numerator) out of the total number of patients identified in CM 02 (denominator).

This applies to the following Programs and Years:

Care planning supports patients identified for care management in CM 01 in managing their care to achieve target goals. Advance care planning (KM 02 I) is the care planning process with an end of life focus to address patient care when they cannot speak for themselves or are at the end of life.
 

This applies to the following Programs and Years:

Although “older adult patients” is an acceptable criterion for social determinants, it should be based on patients’ access to care or needs due to their social situation (e.g., living alone, not being able to drive to an appointment, food insecurity). Because social aspects associated with age may not apply to all patients over 65, Medicare enrollment alone may not be the best indicator.
Remember that patients identified in CM 01 are those who may benefit from care management and for whom a care plan is expected in the criteria outlined in Competency B. If the population is large because it includes all Medicare patients, the practice may want to reexamine the criteria to ensure that appropriate patients are identified.
 

This applies to the following Programs and Years:

A care plan is based on the acute, chronic and preventive care needs of a patient and can include patient preferences and goals; treatment goals and status; assessment of barriers and strategies to address them; current problems and medications; allergies; and a self-care plan. This criterion requires practices to document a patient-centered view of the care plan and share the plan with the patient. A care plan does not need to be re-created at each visit but must be reviewed and updated as needed.

This applies to the following Programs and Years: