FAQ Directory: Patient-Centered Medical Home (PCMH)

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.

This applies to the following Programs and Years:

Examples of immunizations for an adult patient population include flu shots, pneumonia vaccine, shingles vaccine and tetanus.

This applies to the following Programs and Years:

The intent of KM 03 is for the practice to implement universal screening for depression based on guidelines, so all adult and adolescent patients must be included. The practice should have a process to routinely screen patients and the frequency at which the screening is conducted should be based on evidence-based guidelines. The documented process should also include what follow-up occurs for positive screens.

This applies to the following Programs and Years:

Yes. Medication reconciliation (KM 14) includes the process to check for drug and condition interactions in addition to confirming the list of medications with the patient (KM 15). The evaluator may probe for the practice’s process to confirm the same report can be used.

This applies to the following Programs and Years:

This applies to the following Programs and Years:

No. Practices must ask about all medications prescribed to the patient and assess their efficacy, especially for patients identified in CM 01 as needing care management. Patients may have multiple comorbidities and medications, so it is crucial to evaluate their response and barriers to adherence for all medications prescribed to them.

This applies to the following Programs and Years:

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.

This applies to the following Programs and Years:

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

This applies to the following Programs and Years:

No. Services must be distinct for each category.

This applies to the following Programs and Years:

Yes. Use of PHQ-2/PHQ-9 meets the requirement if practices demonstrate its use in monitoring depression treatment and provide an example of the tool’s implementation in clinical care and decision making at the point of care. The intent of KM 20 A is to implement clinical decision support during treatment, not for screening or diagnosis of a mental health condition. Practices that use an evidence-based tool built into the EHR or as part of a workflow in accordance with clinical guidelines can meet the requirements if they demonstrate the guideline and an example of the guidelines implementation (i.e., the tool’s use).

This applies to the following Programs and Years:

The U.S. Preventive Services Task Force (USPSTF) states that adults and adolescents should be screened for depression when a practice has access to services that can be used for follow-up, if there is a positive result (i.e., mental health providers within the practice or external to the practice to whom the practice can refer patients). To meet KM 03, practices are expected to have an approach to follow up and act on results.

This applies to the following Programs and Years:

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).

This applies to the following Programs and Years: