FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.24.2018 CM 01E Does a patient referral for care management from an ED meet the requirements of this item within CM 01?

Yes. This factor requires a documented process for handling referrals made by outside organizations (e.g., insurers, health system, ACO, other providers), practice staff or patient/ family/caregiver for patients that might need additional care management support; an ED is an outside organization.
Note: A report or patient list of referrals is not required for this factor.
 

PCMH 2017

5.24.2018 CM 01D Is identifying a Medicare patient population considered a social determinant of health?

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.
 

PCMH 2017

5.24.2018 KM 16 Do excerpts from medical records indicating that new medications and side effects were reviewed with the patient/family/caregiver meet the requirement?

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.

PCMH 2017

5.24.2018 CM 04 How is advance care planning different from care planning?

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.
 

PCMH 2017

5.24.2018 KM 16 May practices provide new prescription information only for medications relevant to a specific disease of interest?

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

5.24.2018 CM 04 What are the parameters for a care plan?

A care plan is based on the acute, chronic and preventive care needs of a patient and can include patient preferences and goals; treatment goals and status; assessment of barriers and strategies to address them; current problems and medications; allergies; and a self-care plan. This criterion requires practices to document a patient-centered view of the care plan and share the plan with the patient. A care plan does not need to be re-created at each visit but must be reviewed and updated as needed.

PCMH 2017

5.24.2018 KM 20 G What qualifies as an overuse or inappropriateness issue?

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

5.24.2018 KM 01 What kind of report is NCQA looking for as evidence, and what is the required reporting period

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.

PCMH 2017

5.24.2018 QI 01 B May practices use well visits for adult and pediatric patients?

Yes. Practices that see both adult and pediatric patients may use assessment of well-child and well adult visits as two distinct preventive care measures because the two services are based on different evidence-based guidelines.

PCMH 2017

5.24.2018 KM 02 Are practices required to capture information on the entire patient population for the comprehensive health assessment?

Yes. A comprehensive health assessment should be conducted for all patients and described in a documented process so the practice has relevant and documented information about patients' physical health and social and behavioral influences. That information is then utilized to provide appropriate services, interventions and resources to the patient population.

PCMH 2017

5.24.2018 QI 02A May practices submit a measure for completed mammograms as a care coordination measure?

A measure evaluating completed mammograms qualifies as a care coordination measure if the practice is evaluating the rate of mammography results received (numerator) to mammography’s ordered (denominator). For QI 02A, NCQA wants to evaluate gaps in communication or coordination between members of the care team (providers and patients). Measuring the practice’s mammography rates does not meet the intent of a care coordination measure, but measuring timely receipt of results of a referral meets the intent.

PCMH 2017

5.24.2018 KM 02 Is there a percentage threshold requirement for the 9 items within KM 02

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