FAQ Directory: Patient-Centered Medical Home (PCMH)

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4.07.2020 TC 04 & QI 17 Can a large organization meet TC 04 and QI 17 through a shared Patient and Family Advisory Council (PFAC)?

Organizations may share a Patient and Family Advisory Council (PFAC) among sites as long as every site has representation on the council. Large organizations with many sites may consider creating multiple PFACs based on region or clinic type.

PCMH 2017

4.07.2020 CM 01 Could a chronic condition be considered under the high cost/high utilization category if it is expensive to treat?

The intent behind the high cost/high utilization category is that the practice is actively measuring the total cost of services or how much utilization occurs. A diagnosis of a condition may not be used as a proxy for high cost/high utilization. For instance, measuring the number of patients with uncontrolled asthma would not count under high cost/high utilization, but if those patients have multiple ER visits per year, this would be considered high utilization.

PCMH

4.07.2020 AC 04 For AC 04, must a practice report on calls during and after business hours?

Yes, to meet AC 04 a practice’s report must include calls received both during and after business hours. If the practice has different standard response time expectations during and after business hours, they may format this as two separate reports.

PCMH 2017

4.06.2020 AC 10 & 11 If there is one MD practicing at a site with mid level providers (PA, APRN) would this be considered a solo site for AC 10 and AC 11?

If a PA or an APRN shares a panel of patients with a physician then that team would be considered a solo site since all patients are assigned to the primary provider with a single panel.
If the PA or APRNs that have their own panel of patients and can be selected as a patient’s primary care clinician, the site would not be considered a solo site.

PCMH 2017

12.03.2019 AC 03 How does NCQA define “regular business hours”? Our practice is open from 8 am–5 pm. Would opening from 7 am–4 pm meet the requirements of this criterion?

By “regular business hours,” NCQA means 8 am-5 pm, Monday-Friday. The practice determines its hours of operation. Offering appointments between 7am and 4pm meets the criterion. The intent is that practices provide appointments outside typical business hours, to accommodate patients’ access needs. A practice could also shift staff hours—some staff work from 7 am-4 pm weekdays; some staff work from 8 am-5 pm weekdays—to enhance access.

PCMH 2017

10.11.2019 QI 08 - QI 14 Why are the QI Worksheet and the reports for QI 08 – QI 14 not eligible for virtual review?

Reports submitted for QI often outline a lot of information (baseline performance, goals, actions, and remeasurements) that must be carefully reviewed. By uploading the documents ahead of the virtual review, it gives the Evaluator time to review the data and note areas for clarification.
 

PCMH

7.15.2019 QI 04B Would a Patient Family Advisory Council (PFAC) be acceptable as qualitative feedback for QI 04B?

The evidence must specifically reflect the practice’s patient population. Standalone practices whose PFAC only includes patients and family members from the practice may use it to meet QI 04B. For practices that are a part of an organization with other primary care practices under the same umbrella, a shared PFAC would not meet QI 04B. While an organization with a shared PFAC in most cases cannot use it as evidence for QI 04B, it may be used it to demonstrate shared evidence to meet elective criteria TC 04 (2 credits) and QI 17 (2 credits).

PCMH 2017

5.07.2019 QI 08 & AR QI 03 Would increasing survey response rate qualify as a measure for improving patient experience ( QI 11, AR QI 03)?

No, increasing survey response rate is important in obtaining more representative patient feedback, but would not meet the intent of QI 08 or AR QI 03. The response rate is part of the platform for obtaining the feedback, while the measure for these criteria should be improving the feedback itself.
 

PCMH 2017

5.07.2019 CM 09 Would sending the care plan to outside points of care via a secure, electronic fax meet the intent of CM 09?

No, neither secure, electronic fax noR secure email would meet the intent of CM 09. For CM 09, the practice must demonstrate its capability to make their patient's care plans available securely to other care settings, such as hospitals, specialists, or other care facilities that could be managing patient care. This availability should be at the time the patient is seen, including after hours, and as such should not involve reaching out to the practice for the information to be sent. The way in which this care plan is shared may vary and NCQA is not prescriptive, but examples include sharing care plans via shared medical records, HIEs or other shared systems that enable staff from different care settings to view the patient's care plan for continuity and optimal care coordination while the patient receives care from multiple settings.
 

PCMH 2017

5.07.2019 QI 02 What are some examples that would qualify as resource stewardship?

For care coordination, the intent of QI 02A is to evaluate the communication/coordination that occurs between providers or providers and patients, so it's generally looking at closing the loop on care coordination tasks/processes. Some examples for care coordination may include but are not limited to:
 
– Reduced % of patients seeing multiple providers (3 or more)
– Medication reconciliation after care transition (MU)
– Follow up with patients or providers to ensure ordered lab or imaging tests were completed
– Follow up with patients following receipt of abnormal test results
– Outreach to patients not recently seen that result in an appointment
– Follow-up phone calls to check on the patient after an ER visit (or hospitalization)
– # patient calls received after hours by the call center were reconciled in the patient record and addressed by the care team the next business day
– Following up on pediatric visits to after-hours care
– Number of referrals sent
– % of patients who had a positive TB screen who had a FU Chest x-ray
– % of patients who had a positive GC/Chlamydia who were treated with antibiotics
 
 
The intent of QI 02B is for practices to use measures to help them understand how efficiently they're providing care and judiciously using resources. Examples of measures affecting health care costs may include but are not limited to:
 
– Total cost per patient
– Medical cost per medical visit
– # of medications prescribed
– Use of high cost medications
– Use of imaging for low back pain
– Redundant imaging or lab tests
– Emergency department utilization
– Hospital readmission rates
– Use of generic versus brand name medication
– # of Specialist referrals
– # of patients who went to urgent care during open office hours
– # of referrals/ED visits for needs that could be addressed in the office
– Appropriate testing for children with pharyngitis
– Appropriate treatment for children with URI
 

PCMH 2017

3.12.2019 PCMH Criteria and HIEs Can utilization of a Health Information Exchange (HIE) meet PCMH criteria?

Participating in an HIE can help practices demonstrate PCMH criteria; however, connection alone does not demonstrate the evidence needed to meet the following criteria. Practices must demonstrate how they use the HIE to meet each criterion. Utilization of an HIE could help meet the following criteria:
 

PCMH Criteria 

NYS PCMH  
Required Criteria 

AC 12(2 Credits) 

Continuity of Medical Record Information 

✔ 

CM 09(1 Credit) 

Care Plan Integration 

✔ 

CC 15(Core) 

Sharing Clinical information  

 

CC 17(1 Credit) 

Acute Care After-Hours Communication 

 

CC 18(1 Credit) 

Information Exchange During Hospitalization 

 

CC 19(1 Credit) 

Patient Discharge Summaries 

✔ 

CC 21(Maximum 3 Credits) 

External Electronic Exchange of Information 

✔  
(A is required) 

PCMH 2017

1.24.2019 KM 02G Resource