FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.24.2018 KM 20 A Does use of the PHQ-2 or PHQ-9 meet the requirements of KM 20 A?

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).

PCMH 2017

5.24.2018 KM 02F What is NCQA looking for when assessing a patient’s social functioning?

For social functioning, NCQA is looking for the practice to assess and document an individual's ability to interact with others, to maintain relationships with friends or perform work. Several scales for the evaluation of social functioning are available (e.g., SFQ, SASS, GAF); however, NCQA does not require practices to utilize a standardized evaluation tool. If the practice does not elect to implement a specific assessment tool, it may consider developing its own set of questions based on its patient population. There may be some aspects of social functioning that the care team can determine by observation.

PCMH 2017

5.24.2018 CM 01D What are examples of social determinants of health?

Social determinants of health are conditions in the environment that affect a wide range of health, functioning and quality-of-life outcomes and risks and include:

  • Availability of resources to meet daily needs.
  • Access to educational, economic and job opportunities.
  • Public safety, social support.
  • Social norms and attitudes.
  • Exposure to crime, violence and social disorder.
  • Socioeconomic conditions.
  • Residential segregation.

Source: Healthy People 2020: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health.
 

PCMH 2017

5.24.2018 KM 03 Clarify the language in the guidance stating, “screening for adults for depression with systems in place to assure accurate diagnosis, effective treatment and follow-up.”

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.

PCMH 2017

5.24.2018 QI 01 B May practices use well-child visits for two different preventive care measures?

Practices may only count well-child visits for different age groups as distinct preventive care measures if the measures are aimed at assessing completion of age-specific screenings and tests (e.g. autism screen at 2-year check-up, adolescent depression screen), according to evidence-based guidelines. Assessing patient access to well visits for two different pediatric age groups would not be considered two different measures.

PCMH 2017

5.24.2018 KM 03 Does the practice need to conduct depression screenings for its entire patient population, or only those patients who are symptomatic?

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.

PCMH 2017

5.24.2018 QI 01 C Which patient populations meet the specified measures for category C?

Selection of chronic or acute care measures is determined by prevalent conditions identified by the practice and by evidence-based guidelines.

PCMH 2017

5.24.2018 KM 09 How does NCQA define “another characteristic of diversity”?

Diversity is a meaningful characteristic of comparison for managing population health that accurately identifies individuals within a non-dominant social system who are underserved. Examples of another characteristic of diversity other than race and ethnicity include, but are not limited to, first ancestry, marital status, employment status, education level, housing status and income.

PCMH 2017

5.24.2018 QI 02A What are care coordination measures?

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).

PCMH 2017

5.24.2018 QI 01 Can a practice use a measure such as depression screenings to meet both QI 01B and QI 01D

No, a measure cannot be used twice even though it could fit under two categories.

PCMH 2017

5.24.2018 CM 01C Does our practice meet the requirements if we use 65 years of age and older as the criterion for patients with poorly controlled or complex conditions?

No. Using only this age group does not meet the requirements. Identification of poorly controlled or complex patients can include older patients (e.g., >65 years) who also meet other high-risk criteria such as co-morbid conditions, frequent hospitalizations, mental health problems or frailty.

PCMH 2017

5.24.2018 KM 10 How can we best collect language needs information from all patients in our large population?

Practices could use a variety of methods to collect language needs information on a large patient population. They may collect data from all patients and their families to create a report showing language needs or obtain data from an external source (e.g., data about the local community or its patient population). 

Patients who do not speak English and patients from racial/ethnic minority groups may be less inclined to provide this information. Care should be taken to request the information using methods that respect multi-cultural differences. 

Resource: NCQA’s 2010 Multicultural Health Care Standards (Abbreviated) E-Pub: http://store.ncqa.org/index.php/2010-mhc-standards-and-guidelines-electronic-pub.html  

PCMH 2017