No. For criterion PP 01, the care manager function must be filled by practice staff
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8.16.2018 PP 01 Our practice offers telepsychiatry. Does this meet the requirement for a care manager qualified to manage behavioral health?
8.16.2018 General Why did the Massachusetts Health Policy Commission (HPC) create the PCMH PRIME Certification program?
Behavioral health conditions (mental illnesses and substance use disorders) suffer from both under-diagnosis and delayed diagnosis. This is a serious public health problem nationally and across the Commonwealth. Untreated behavioral health conditions contribute to morbidity and increase the total cost of care. The gap in care and treatment for behavioral health conditions requires action and a coordinated effort by providers and payers to ensure that patients get the care they need, before illness is severe and results in a crisis situation (e.g., avoidable ED visit or inpatient admission). Integrating behavioral health—including appropriate screening for behavioral health conditions (and treatment, when appropriate)—is critical in the primary care setting.
This applies to the following Programs and Years:
8.16.2018 PP 02 Our practice offers telepsychiatry. Does this meet the requirement for a clinician providing medication assisted treatment (MAT)?
Yes. A practice may satisfy criterion PP 02 by having a prescribing clinician who is accessible through telehealth, provided that the clinician is integrated into the practice’s workflow for MAT (e.g., can exchange patient information with the practice site, as appropriate).
This applies to the following Programs and Years:
8.15.2018
Updated: Use of Acronyms in UM Denial and Appeal Notices In UM 7, Elements B, E and H and UM 9, Element D, the explanation under Factor 1: states that the reason for denial should not include abbreviations or acronyms that are not defined. Similar language is in UM 8 A.
Does this mean that they must be spelled out (e.g., “We are denying your request for a deoxyribonucleic acid (DNA) test because…”) or explained (“We are denying your request for a DNA test, which is a test that looks at your genetic information in order to…”), or both?
The intent of the requirement is that the denial or appeal notice be written in language that can be easily understood by members. Because abbreviations/acronyms may include terms that are not easily understood, even when spelled out, they must be explained. NCQA is updating the explanation under each applicable factor of the referenced elements to read:
The denial [appeal] notification states the reason for the denial [upholding the denial] in terms specific to the member’s condition or request and in language that is easy to understand, so the member and practitioner understand why the organization denied the request [upheld the denial] and have enough information to file an appeal.
An appropriately written notification includes a complete explanation of the grounds for the denial, in language that a layperson would understand, and does not include abbreviations, acronyms or health care procedure codes that a layperson would not understand. The organization is not required to spell out abbreviations/acronyms if they are clearly explained in lay language. Denial [Appeal] notifications sent only to practitioners may include technical or clinical terms.
NCQA will post an update in December for the 2018 and 2019 HP and UM-CR-PN and 2018 MBHO publications to reflect this change.
This applies to the following Programs and Years:
HP 2018, 2019|MBHO 2018|UM-CR-PN 2018, 20198.02.2018 PP 08 Does the practice need to conduct depression screenings for its entire patient population, or only those patients who are symptomatic?
The intent of PP 08 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:
8.02.2018 PP 06 What is the required frequency for a patient health assessment?
NCQA does not prescribe a frequency; practices determine the time frame for conducting and updating patient health assessments according to a protocol that suits their patient population, aligns with evidence-based guidelines and allows for meaningful evaluation of data.
This applies to the following Programs and Years:
8.02.2018 PP 06 Would unhealthy behaviors associated with a parent’s behavior be acceptable for PP 06 since they are responsible for preventing these behaviors?
Yes, unhealthy behaviors can be the result of parent behavior but ultimately, we're looking for the unhealthy behaviors demonstrated by the patient (child). Secondhand smoke may be a direct example of a parent’s behavior affecting the child’s health and poor oral hygiene may be a child’s unhealthy behavior, but could result from lack of parental oversight or health literacy.
This applies to the following Programs and Years:
8.02.2018 PP 08 What type of standardized screening tool for depression would meet the requirement for a pediatric population?
NCQA is not prescriptive regarding which depression screening tool is used as long as it’s a standardized tool. Some depression screening tool examples that would be appropriate for adolescents include but are not limited to PHQ2, PHQ9, PHQ-A, PSC, PSC-Y, RAAPS, or HEADSS.
This applies to the following Programs and Years:
8.02.2018 PP 08 Clarify the language in the guidance stating, “screening for adults for depression with systems in place to assure accurate diagnosis, effective treatment and follow-up.”
The U.S. Preventive Services Task Force (USPSTF) states that adults and adolescents should be screened for depression when a practice has access to services that can be used for follow-up, if there is a positive result (i.e., mental health providers within the practice or external to the practice to whom the practice can refer patients). To meet KM 03, practices are expected to have an approach to follow up and act on results.
This applies to the following Programs and Years:
8.02.2018 PP 06 Are practices required to capture information on the entire patient population for the comprehensive health assessment?
Yes. A comprehensive health assessment should be conducted for all patients and described in a documented process so the practice has relevant and documented information about patients' physical health and social and behavioral influences. That information is then utilized to provide appropriate services, interventions and resources to the patient population.
This applies to the following Programs and Years:
8.02.2018 PP 06 What is the required frequency for a patient health assessment?
NCQA does not prescribe a frequency; practices determine the time frame for conducting and updating patient health assessments according to a protocol that suits their patient population, aligns with evidence-based guidelines and allows for meaningful evaluation of data.
This applies to the following Programs and Years:
8.02.2018 PP 04 Our practice has agreements with and shares patient records with behavioral healthcare providers, but we do not share the same EHR or physical location. Do we meet the requirement for integrating behavioral healthcare in our practice?
No. Although there is no requirement for a behavioral healthcare provider to be physically in the practice’s office, the behavioral healthcare provider must have at least partial access to the practice’s systems. Although the arrangements mentioned meet the intent of PP 03 (maintaining agreements with behavioral healthcare providers), they do not meet the requirements for this criterion.
If a practice site in an organization has integrated behavioral healthcare, the other sites in the organization may receive credit if there is also a process for their patients to access those behavioral healthcare services.
AAP resource:
Strategies for System Change in Children’s Mental Health: A Chapter Action Kit developed by the American Academy of Pediatrics (AAP) Task Force on Mental Health assists AAP chapters in addressing and improving children’s mental health in primary care in their state. https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Pages/Chapter-Action-Kit.aspx
