FAQ Directory: Patient-Centered Medical Home (PCMH)

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10.12.2018 KM 07 For KM 07, should the required report outline what percentage of patients have a social determinant of health noted in the chart, or should the report include what the social determinants are and what percentage of patients fall under each?

Elective criterion KM 07 goes beyond providing the percentage of patients with social determinants of health documented in the medical record; the report should include the breakdown by social determinant(s) so the practice understands which social determinants impact their patients to better implement appropriate care interventions. The intent of elective criterion is for the practice to show how it monitors social determinants of health at the population level for its patient population and also how it uses that data to address and assist in overcoming those social determinants of health. Reports may be generated from data collected in KM 02 G.

PCMH 2017

10.12.2018 BH 06 How would a practice fulfill this criteria if they are already fully integrated?

A practice with integrated behavioral health may provide its documented process and evidence of implementation. For evidence of implementation, the practice might demonstrate the practice's internal process for entering patient treatment notes, referral guidance and medication management within its system and how the integrated BH provider updates the PCP about the patient's progress. The documented process may also include how the practice facilitates transition to BH, such as through warm handoffs.

PCMH 2017

10.12.2018 CM 04 - CM 08 Is there a minimum threshold a practice must meet for these criteria?

The expectation is that these facets of the care plan should be happening routinely. NCQA has not set a specific threshold, however if the practice is reporting less than 75% the evaluator may question whether the practice has truly implemented the criteria as part of their care plan routine.

PCMH 2017

10.12.2018 CM 05 If a practice offers to print a care plan for the patient but the patient declines, would this count as a 'Yes' or 'No' in the numerator.

If the practice offers to print the care plan and the patient declines, the practice may count the patient as a 'Yes'.

PCMH 2017

9.07.2018 KM 13 Would the annual UDS report, by which FQHC’s are required to submit data to HRSA, be acceptable to provide as a report?

For FQHCs that are part of a larger organization with multiple practices under the same umbrella, UDS reporting would not meet KM 13 because the data is at the organizational/corporate level. The data for KM 13 must be at the practice level because recognition is at the practice level. An exception to this is for standalone practices whose UDS data is specific to the practice site location.

PCMH 2017

7.18.2018 AC 07 (Pediatric Specific) How do practices account for adolescent confidentiality issues; for example, if an adolescent asks that information not be shared with a parent?

Pediatric practices are not penalized for not sharing information with parents if the adolescent requests that information not be shared, but applicants must explain the exclusion of adolescent patients in the associated documentation. The system must include only legitimate requests for information based on state and federal confidentiality requirements

AAP resources:  

PCMH 2017

7.18.2018 CM 04 (Pediatric Specific) Where can I find an example of a patient care plan for a pediatric patient- centered medical home?

7.18.2018 CC 10 (Pediatric Specific) AAP resource:

7.09.2018 KM 08 (Pediatric Specific) Are there health literacy training programs tailored to pediatric practices?

No, but health literacy training programs are only a suggested approach for addressing communication needs and reducing barriers for patients and their families to access and understand health and safety information.

  • AAP resources: 
           – AAP Pedialink course on health literacy: https://shop.aap.org/health-literacy/  
  • Other resources:
HRSA: Culture, Language, and Health Literacy Tools & Resources: https://www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/resources/index.html  



PCMH 2017

6.14.2018 KM 12B (Pediatric Specific) Do Tdap and DTaP count as two different immunizations?

No. Although the immunizations are different formulations, Tdap and DTaP are integrally related. For this reason, NCQA considers them the same immunization for different age groups and does not accept them as two different immunizations.

PCMH 2017

6.14.2018 KM 24 (Pediatric Specific) • AAP resource:

− Shared Decision-Making in Pediatrics: A National Perspective Pediatrics 2010;126;306: 

PCMH 2017

6.14.2018 KM 02F (Pediatric Specific) How do clinicians assess the pediatric patient's ability to interact with other kids in a normal fashion? If the child is functioning normally in school would that suffice?

A social-emotional screening tool would be the best route to assess this, and the recommendation is for that screening to be done on a regular basis.

PCMH 2017