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No. Using only this age group does not meet the requirements. Identification of poorly controlled or complex patients can include older patients (e.g., >65 years) who also meet other high-risk criteria such as co-morbid conditions, frequent hospitalizations, mental health problems or frailty.
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.
Social determinants of health are conditions in the environment that affect a wide range of health, functioning and quality-of-life outcomes and risks and include:
Source: Healthy People 2020: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health.
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.
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.
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.
Yes. This factor requires a documented process for handling referrals made by outside organizations (e.g., insurers, health system, ACO, other providers), practice staff or patient/ family/caregiver for patients that might need additional care management support; an ED is an outside organization.
Note: A report or patient list of referrals is not required for this factor.
Practices define “timely” advice after considering the needs of their population. Practices must submit their written policy for responding to calls and e-mails, which may categorize the types of requests and appropriate response times.
Practices must also monitor and demonstrate their documented process defining response times to a nonurgent message and a report summarizing response times.
Yes. The requirement is met if the response time is documented when a patient submits an electronic request for clinical advice and the practice communicates to patients that an on-call provider is available to address urgent issues by telephone after hours. Practices must have a documented process for addressing electronic advice and telephone advice; for this criterion, practices may submit a report tracking response times to electronic requests for at least seven days during operating hours and after hours.
Practices are expected to show both availability (i.e., open appointment slots at the beginning of the day) and use of same-day appointments for a period of five consecutive days. Practices should also monitor the availability of same-day appointments against their documented process. Practices may use utilization of same-day appointment access as an indication of patient need.
