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No. Practices may demonstrate the same evidence if:
Practices must provide information about how the letter, phone script or other method is modified for each service reminder.
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.
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.
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
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.
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.
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).
No. PQRS reports and Medicare Shared Savings Program (MSSP) would not meet the requirement. For KM 13, practices must demonstrate they participate in an external program that assesses practice-level performance, using a common set of specifications to benchmark results. The external program should also publicly report results and have a process to validate measure integrity.
PQRS is not a performance-based recognition program and is being rolled into MIPS under the Quality Performance category. The MSSP makes data on Accountable Care Organizations (ACOs), rather than at the practice level, publicly available. Because this criterion is not eligible for shared credit, data is required to be at the practice level.
While participation in these programs does not meet KM 13, practices can use participation in MSSP to meet QI 19. Practices in Track 1 MSSP, would be eligible for QI 19 A (1 credit), and practices in Track 2 MSSP would be eligible for QI 19 B (2 credits).
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.
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).
