FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.22.2018 CM 01 What’s the difference between CM 01 and CM 03 as both look at identifying high risk patients?

CM 01 focuses on the practice’s established criteria and systematic process for identifying patients in need of care management. Comprehensive risk stratification in CM 03 requires a more complex identification process than that of CM 01. CM 03 goes beyond simply establishing criteria and provides elective credit to practices that are using a risk assessment process to identify patients for care management, leveraging clinical data about the patients; it is about stratifying patients using all the factors that put the patient at higher risk and in need of assistance in managing their health. If a practice meets CM 03, it will automatically meet CM 01.

PCMH 2017

5.22.2018 CM 01A Does tobacco use count as a behavioral health condition?

No. Tobacco use is an unhealthy behavior and is not considered a behavioral health condition. Practices need to identify behavioral health-related criteria pertinent to their specific patient population, which could include other (non-tobacco-related) substance use treatment, a behavioral health diagnosis, a positive screening result from a standardized behavioral health screener or psychiatric hospitalizations.

PCMH 2017

5.22.2018 AC 01 What are examples for how and where practices should collect data to address AC 01?

The intent of AC 01 is to assess the access needs and preferences of the practice’s patient population. To identify the best way to obtain this information, practices may need to review how they are currently collecting patient feedback on access needs. For example, a patient survey may ask patients if they are able to get an appointment when needed; however, that question doesn't tell you when patients want to access the practice. The practice may be offering access when the majority of patients don't or aren't able to utilize it.
Practices should collect and assess the feedback from patients to see if there's a need to adjust the access provided to patients. Some questions to   consider include:

  1. What data are you already collecting on patient access (e.g. surveys, use of appointments)? Is it current and does it cover the whole patient population?
  2. How often do you need to assess the access needs of your patients?
  3. What variables may impact changes in the use of appointment types?
  4. If using patient satisfaction surveys, how many patients are actually responding? If the response rate is low, is there another mode of collecting feedback to get more input.
  5. Do the questions on your survey ask patients directly about their access needs or preferences?

PCMH 2017

5.22.2018 AC 02 Are practices required to measure their capacity to see patients or to measure the utilization of same-day appointments (i.e., number of patients seen)?

Practices are expected to show both availability (i.e., open appointment slots at the beginning of the day) and use of same-day appointments for a period of five consecutive days. Practices should also monitor the availability of same-day appointments against their documented process. Practices may use utilization of same-day appointment access as an indication of patient need.

PCMH 2017

5.22.2018 AC 02 Are practices required to reserve separate same-day appointment slots for routine and urgent visits?

No. Practices must show appointment slots that are available for both urgent/acute and routine care, but may have a policy to accommodate patients with urgent/acute care needs first.

PCMH 2017

5.22.2018 AC 02 Are practices required to provide a minimum number of same-day appointments?

NCQA does not specify a minimum number of same-day appointments per day for practices, and not all clinicians must offer same-day appointments.

PCMH 2017

5.22.2018 AC 02 Our clinic has walk-in appointments available every day. Do these count as same-day appointments?

No. Walk-in appointments are different from scheduled same-day appointments. Same-day appointments offer patients the opportunity to schedule a routine or urgent visit at a specific time to enable more patient-centered and convenient access; this prevents the need to wait for the next available clinician at the clinic.

PCMH 2017

5.22.2018 AC 06 A behavioral healthcare practitioner is integrated with our practice and provides telepsychiatry visits. Does this meet the requirement for an alternative clinical encounter?

Yes. NCQA accepts telepsychiatry visits as an alternative clinical encounter if the behavioral healthcare practitioner is at least partially integrated with the practice site (i.e., sharing at least partial access to the same systems and patient records).

PCMH 2017

5.22.2018 AC 13 Is it mandatory to use the American College of Family Physicians mentioned in the guidance for determining panel sizes?

No. The ACFP tool is a helpful resource for practices to use when considering and managing panel sizes. If the practice prefers to use another method that is perfectly acceptable if it performs the same function.

PCMH 2017

5.22.2018 AC 06 Can a nurse be scheduled for an alternative appointment with a patient?

Yes, members of the clinical staff (including clinicians and nurses) providing clinical care to patients (based on pertinent licensing laws) may be scheduled for an alternative appointment with a patient. These appointments are in place of those scheduled in the physical office and provided by telephone or other technology supported mechanisms. Visits with social workers, nutritionists, educators or pharmacists alone without an accompanying staff member administering clinical care would not meet the intent of the criterion.

PCMH 2017

5.22.2018 AC 12 Our practice offers night and weekend clinical advice coverage to patients through a phone service staffed by RNs. Does this meet the requirement for access to clinical advice?

Yes, if the phone service can provide after-hours access (AC 04) and can access the patient’s medical record either directly or through an available on-call provider with direct access (AC 12).

PCMH 2017

5.22.2018 AC 03 We are a hospital-owned practice; the ED serves as an after-hours clinic. Does this meet the requirements?

No. AC 03 requires practices to offer appointments outside regular business hours for both routine and urgent care. Using the ED for after-hours care does not meet the requirement since patients cannot schedule and access routine appointments at the ED.

PCMH 2017