FAQ Directory

No. The requirement to provide new information applies to all new medications prescribed to a patient, especially for patients identified in Concept CM as needing care management. Patients may have multiple comorbidities and medications, so it is crucial that they receive information about all medications prescribed to them

PCMH 2017

No. While advance care planning could include a completed advance directive, it’s not required to meet KM 02. The practice must demonstrate that it documents results of advance care planning discussions with patients to meet this requirement. If a practice has an advance directive on file and documented in the patient medical record, that would also meet the intent.

PCMH 2017

Practices should provide a report that demonstrates they update patient problem lists based on visits, transfer of information from other providers or information from the patient. As patient problem lists are expected to be updated at least annually, practices will want to monitor their rate on a periodic basis. Practices define the reporting period and frequency that allows meaningful evaluation of data.

PCMH 2017

Practices must collect and document information on what may influence a patient’s overall safety, risk factors, health and well-being. The practice should consider all potential social determinants of health when collecting information from patients; however, practices are not required to have a complete list of every possible social determinant of health assessed for every patient. The purpose of this requirement is to collect information on areas that may be influencing/affecting a patient's health and well-being, many of which could be observed by the clinician/care team. Each practice is unique and there may be social determinants of health that are more common for their patient population as compared to others. Therefore, the practice may want to consider identifying common areas and develop standard questions to ask patients. However, the practice should not limit the assessment to just the most common areas or fields provided in their EHRs, to ensure all relevant information is documented in the patient's medical record.

PCMH 2017

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.

PCMH 2017

For social functioning, NCQA is looking for the practice to assess and document an individual's ability to interact with others, to maintain relationships with friends or perform work. Several scales for the evaluation of social functioning are available (e.g., SFQ, SASS, GAF); however, NCQA does not require practices to utilize a standardized evaluation tool. If the practice does not elect to implement a specific assessment tool, it may consider developing its own set of questions based on its patient population. There may be some aspects of social functioning that the care team can determine by observation.

PCMH 2017

The practice must demonstrate evidence (i.e., patient list/report and outreach materials) of a service reminder provided within the past year for 3 of the 4 categories/items within KM 12. After achieving Recognition, practices are expected to report on reminders on their Annual Report.

PCMH 2017

Adult practices may identify lists of patients needing screenings (e.g., mammograms, colorectal screenings), check-up visits, annual lab testing or well-woman visits. 

Preventive measures must encompass a practice’s entire appropriate population (not only patients with chronic conditions [KM 12 C]). The intent of reminding patients of preventive services is for practices to use their systems to identify specific groups of patients in need of services and to improve the quality of care for all patients in the practice.

PCMH 2017

No. Services must be distinct for each category.

PCMH 2017

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.

PCMH 2017

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.

PCMH 2017

No. The evidence required for KM 02 does not require a report. The practice should outline how it collects and documents this information in its documented process. For evidence of implementation, the practice can demonstrate its process during the virtual check-in, which may include sharing where the information is documented in the patient record.

PCMH 2017