Cadence Thresholds Added:
Cadence thresholds are applied to 45 criteria to ensure continuous improvement and to avoid stagnation in workflows (i.e. “at least annually").
| Criteria Title |
| TC 06: Individual Patient Care Meetings/ Communication |
| TC 07: Staff Involvement in Quality Improvement |
| KM 02: Comprehensive Health Assessment |
| KM 03: Depression Screening |
| KM 04: Behavioral Health Screenings |
| KM 05: Oral Health Assessment |
| KM 06: Predominant Conditions |
| KM 07: Social Determinants of Health |
| KM 09: Diversity |
| KM 11: Population Needs B. Educates practice staff on health literacy and C. Educates practice staff in cultural competence. |
| KM 17: Medication Responses and Barriers |
| KM 21: Community Resource Needs |
| KM 23: Oral Health Education |
| KM 26: Community Resource List |
| KM 27: Community Resource Assessment |
| AC 01: Access Needs and Preferences |
| AC 09: Equity of Access |
| AC 11: Patient Visits with Clinician/Team |
| AC 13: Panel Size Review and Management |
| AC 14: External Panel Review and Reconciliation |
| CM 01: Identifying Patients for Care Management |
| CM 02: Monitoring Patients for Care Management |
| CM 03: Comprehensive Risk Stratification |
| CM 04: Person-Centered Care Plans |
| CM 05: Written Care Plans |
| CM 06: Patient Preferences and Goals |
| CM 07: Patient Barriers to Goals |
| CM 08: Self-Management Plan |
| CM 10: Person-Centered Outcomes Approach |
| CM 11: PCO: Monitoring and Follow-Up |
| CC 06: Commonly Used Specialists Identification |
| CC 07: Performance Information for Specialist Referrals |
| CC 14: Identifying Unplanned Hospital and ED Visits |
| QI 03: Appointment Availability Assessment |
| QI 04: Patient Experience Feedback |
| QI 05: Health Disparities Assessment |
| QI 07: Vulnerable Patient Feedback |
| QI 08: Goals and Actions to Improve Clinical Quality Measures |
| QI 09: Goals and Actions to Improve Resource Stewardship |
| QI 10: Goals and Actions to Improve Appointment Availability |
| QI 11: Goals and Actions to Improve Patient Experience |
| QI 13: Goals and Actions to Improve Disparities in Care/ Service |
| QI 15: Reporting Performance Within the Practice |
| QI 16: Reporting Performance Publicly or With Patients |
| QI 17: Patient/Family/ Caregiver Involvement in Quality Improvement |
ALL 2017