Here are some of the most frequently asked questions about NCQA’s various programs. If you don’t see what you are looking for in one of the entries below, you can ask a question through My NCQA.
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KM 20 G requires evidence-based guidelines on appropriate use of services, which could include a prompt at the point of care to consider appropriateness of laboratory test ordering, avoidance of MRI as a first-line diagnostic test for back pain, appropriateness of antibiotics use, or appropriateness of specific referrals.
NCQA encourages practices to look at ABIM’s Choosing Wisely website for more information on overuse/appropriateness (www.choosingwisely.org).
Use of flow sheets, demonstration of EHR prompts or other evidence of guideline implementation with which the provider is alerted when a specific service or action is needed at the point of care, based on evidence-based guidelines, would meet the intent of KM 20. In addition to the evidence, practices must also provide information on the condition addressed by the clinical decision support and the source of the evidence-based guideline on which the clinical decision support is based.
Flow charts, copies of guidelines or empty templates do not demonstrate implementation of clinical decision support. These items show the guideline, but do not demonstrate its use at the point of care
No. Although it may be duplicate information, practices cannot assume that the pharmacy provided the information to the patient. Communication and partnership with patients are critical functions of the patient-centered medical home, and practices must ensure that patients/families/caregivers understand why medication was prescribed and its benefits and potential harms to the patient. Additionally, patients might not review prescription information provided by a pharmacy, and information might not be tailored to the needs of the patient/family/caregiver.
Diversity is a meaningful characteristic of comparison for managing population health that accurately identifies individuals within a non-dominant social system who are underserved. Examples of another characteristic of diversity other than race and ethnicity include, but are not limited to, first ancestry, marital status, employment status, education level, housing status and income.
Measures of care coordination address communication regarding patient referrals and care transitions.
For example, a practice refers a patient to another provider or a community resource. A care coordination measure might assess whether the referral was completed (i.e., the practice receives the referral report, follows up with the resource or patient to assess use or patient experience).
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.
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.
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.
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.
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.
