FAQ Directory: Patient-Centered Medical Home (PCMH)

CM 02 requires practices to create a process using criteria defined in CM 01 to identify patients for care management. The practice may use any method to identify these patients. For CM 02, practices need only provide a report showing the percentage of patients calculated from the number of patients identified using the defined criteria (numerator) in comparison to the entire patient population (denominator).
Note: Practices select at least three categories (CM 01) to define the subset of the patient population for care management for CM 02, and identify a population for care management (at least 30 patients) so they can report the criteria outlined in Competency B. Patients across the categories identified in CM 01 should be represented in the population identified for CM 02.
 

PCMH 2017

By resource stewardship, we mean ensuring responsible use of resources while providing high quality, efficient, patient-centered primary care as it relates measures affecting health care costs and care coordination.

PCMH 2017

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

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

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

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).

PCMH 2017

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

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

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

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

Yes, this meets the requirement if the telehealth provider is a clinician, provides a scheduled appointment and has access to practice systems and the patient’s medical record.

PCMH 2017

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