FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.24.2018 KM 12 How many activities are required for each item within KM 12?

The practice must demonstrate evidence (i.e., patient list/report and outreach materials) of a service reminder provided within the past year for 3 of the 4 categories/items within KM 12. After achieving Recognition, practices are expected to report on reminders on their Annual Report.

PCMH 2017

5.24.2018 KM 02 What if the patient answers “No” or does not want to provide information?

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. 

PCMH 2017

5.24.2018 KM 12 A May practices use depression screening for both KM 12 A and C?

No. Services must be distinct for each category.

PCMH 2017

5.24.2018 KM 02 What is the required frequency for a patient health assessment

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.

PCMH 2017

5.24.2018 KM 12 B What are examples of adult immunizations?

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

PCMH 2017

5.24.2018 KM 02 G What are the expectations for assessing a patient’s social determinants of health? How many social determinants are required for each patient? Are any specific social determinants required to be collected?

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

5.24.2018 KM 14 Can the same report be used if the practice does medication reconciliation at least annually? How is KM 14 different from KM 15?

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.

PCMH 2017

5.24.2018 KM 02 H What evidence demonstrates use of a developmental screening tool?

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. 

PCMH 2017

5.24.2018 KM 16 Isn’t supplying information on all new prescriptions redundant since the same information is provided by a pharmacy?

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.

PCMH 2017

5.24.2018 KM 02 I Is a patient’s advance directive required to be included in the medical record?

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

5.24.2018 KM 17 May practices assess response only to medications treating a specific disease of interest?

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.

PCMH 2017

5.24.2018 KM 02 I Do patients of all ages need to be included in this requirement?

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.

PCMH 2017