An informal agreement could be a few sentences in a referral form, e-mail or other method of communication containing expectations for the specialist, including, but not limited to, the time frame for reporting to the primary care physician and specifying lab or test results that should be included in the report. This information is essential to clarify the relationship between the primary care provider and specialist.
PCMH 2017
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).
PCMH 2017
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
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).
PCMH 2017
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.
PCMH 2017
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.
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
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 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
