FAQ Directory: Patient-Centered Medical Home (PCMH)

No. The practice needs to demonstrate that they collect both quantitative and qualitative data to meet the requirement.

This applies to the following Programs and Years:

Yes. Practices that use integrated systems must demonstrate how specialists are notified of a referral request and how the referral status will be tracked (including the specialist’s report). Even if the same EHR is used by both the primary care practitioner and the specialist, evidence must clearly demonstrate how the requirements are met within the system.
 

This applies to the following Programs and Years:

No. Credentialing—although important to a clinician’s ability to practice—is not a specific indicator of performance or quality information. Practices must use performance data to evaluate the quality of specialists or consultants to whom they send patients. Performance data can be qualitative or quantitative and may be gathered from external reporting sources (e.g., PCSP recognition, CMS public reporting) or may be internal based on criteria defined by the practice (e.g., evaluating a specialist’s timeliness in returning referral reports, evaluating whether patients had a positive experience). 
 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

No. For KM 16, the practice must both (1) generate a report that demonstrates more than 50 percent of patients have documentation in their medical record that they were assessed and provided education on new prescriptions and (2) demonstrate evidence of the process, which could include showing a patient medical record during virtual review. It is up to the practice to determine the best method for sharing new medication information with patients, and the practice should consider patient language, literacy and health literacy in providing information or materials.

This applies to the following Programs and Years:

Practices could use a variety of methods to collect language needs information on a large patient population. They may collect data from all patients and their families to create a report showing language needs or obtain data from an external source (e.g., data about the local community or its patient population). 

Patients who do not speak English and patients from racial/ethnic minority groups may be less inclined to provide this information. Care should be taken to request the information using methods that respect multi-cultural differences. 

Resource: NCQA’s 2010 Multicultural Health Care Standards (Abbreviated) E-Pub: http://store.ncqa.org/index.php/2010-mhc-standards-and-guidelines-electronic-pub.html  

This applies to the following Programs and Years:

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:

Medical records should clearly indicate that the patient has been asked about the specific item by including a notation that the patient answered “No” or declined to answer. Practices do not lose credit if the patient says “No” or declines to answer as long as it is documented. 

This applies to the following Programs and Years:

Practices must demonstrate:

* An example of the criterion documented in the patient record, and

* A completed developmental screening form. 

or

* A report, and

* A completed developmental screening form. 

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

Care planning supports patients identified for care management in CM 01 in managing their care to achieve target goals. Advance care planning (KM 02 I) is the care planning process with an end of life focus to address patient care when they cannot speak for themselves or are at the end of life.
 

This applies to the following Programs and Years:

No. Practices with a patient sample that includes both pediatric and adult patients for reporting provide at least one pediatric example and at least one adult example for the criteria outlined in Competency B, but are not required to provide a pediatric example and an adult example for each criterion.

This applies to the following Programs and Years: