FAQ Directory: Patient-Centered Medical Home (PCMH)

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5.29.2018 CC 08 What is an example of an informal agreement?

An informal agreement could be a few sentences in a referral form, e-mail or other method of communication containing expectations for the specialist, including, but not limited to, the time frame for reporting to the primary care physician and specifying lab or test results that should be included in the report. This information is essential to clarify the relationship between the primary care provider and specialist.
 

PCMH 2017

5.29.2018 QI 11 May practices focus on improving the number of patient experience survey responses it receives back from patients?

No. A measure looking to increase the number of patients who complete the satisfaction survey would not meet the requirement. Practice should look at improving an area identified using the patient experience data collected in QI 04.

PCMH 2017

5.29.2018 CC 10 (PP 04) Our practice has agreements with and shares patient records with behavioral healthcare providers, but we do not share the same EHR or physical location. Do we meet the requirement for integrating behavioral healthcare in our practice?

No. Although there is no requirement for a behavioral healthcare provider to be physically in the practice’s office, the behavioral healthcare provider must have at least partial access to the practice’s systems. Although the arrangements mentioned meet the intent of CC 09 (maintaining agreements with behavioral healthcare providers), they do not meet the requirements for this criterion. 

If a practice site in an organization has integrated behavioral healthcare, the other sites in the organization may receive credit if there is also a process for their patients to access those behavioral healthcare services.  

PCMH 2017

5.29.2018 CM 04 Does a clinical summary meet the requirement for a “plan of care”?

If the clinical summary also includes the details of the patient’s care plan (i.e., information outlined in the criterion guidance), then it would meet the requirement. A clinical summary alone that does not include the patient’s care plan information would not meet the requirement.

PCMH 2017

5.29.2018 QI 12 How do practices assess the effectiveness of improvement actions?

Assessing effectiveness of improvement actions includes remeasurement to compare results over time and evaluation of what is driving change. Results may be quantitative (numerical data that demonstrate performance and can be compared to benchmarks) or qualitative (conceptual data that describe why performance is high or low), but practices must look at the goals set, actions taken to improve and previous or baseline results.

PCMH 2017

5.29.2018 QI 11 May practices focus on improving results of a specific question in a patient experience survey?

Yes. Practices determine the area of patient experience on which to focus quality improvement efforts. This may be improvement of the results of a specific question on a survey, a section of a survey or the entire survey.

PCMH 2017

5.29.2018 QI 15 May a practice with one clinician provide the same evidence for both clinicians and staff in QI 15?

Yes. Because the practice has only one clinician, practice-level data would be the same as clinician-level data, and therefore count for both.

PCMH 2017

5.29.2018 QI 08 May “improve performance” be a stated performance goal?

No. The performance goal must be quantified (e.g., a number or percentage signifying a specific performance level).

PCMH 2017

5.29.2018 QI 06 Is CAHPS a requirement for this measure?

No. Any standardized (non-proprietary) survey administered through measurement initiatives providing benchmark analysis external to the practice organization may be used to meet QI 06. Please note that the practice must administer the entire standardized survey (not just sections) so that it can be compared to available benchmarks.

PCMH 2017

5.29.2018 QI 05 How can practices stratify data for vulnerable populations?

Practices select a vulnerable population for measurement using fields that are available in their practice system. Practices may use categories such as race, age, ethnicity, language needs, education, income, type of insurance, disability or health status to identify specific populations that may experience disparities in care.

PCMH 2017

5.29.2018 QI 04B May practices use the “comments” section in the patient experience survey to meet this requirement?

No. Comment sections or “free text” questions on a patient experience survey do not meet the requirement as a method of collecting qualitative feedback from patients and their families.

PCMH 2017

5.29.2018 CM 05 May practices make the individualized care plan available via patient portal, or are they required to provide the document in writing?

Although the care plan can be made available via the patient portal, it is essential that all patients have access to the document. If patients are not registered for the portal, they will not have access. In those cases, practices should use an alternative method to provide the written care plan to patients to ensure that all patients have access after an appointment. Please note practices must document that the care plan is provided to the patient in the patient’s medical record.
 

PCMH 2017