2014 - PCMH5B

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The practice:

5.B.1 Considers available performance information on consultants/specialists when making referral recommendations.

According to NCQA, the practice uses available data on the performance of clinicians and practices it refers its patients to. Examples include state physician report cards, health plan directories and the CMS Web site http://www.medicare.gov/physiciancompare.

5.B.2 Maintains formal and informal agreements with a subset of specialists based on established criteria.

According to NCQA, agreements between primary care and the specialist may be formal or informal and may describe the expectations or embed them in a tool such as a referral request form. The agreement is an articulation of the arrangements for the exchange of information. Agreements typically indicate the type of information that will be provided when referring a patient to a specialist and expectations regarding timeliness and content of response from the specialist.

You will need to provide NCQA with one example.

5.B.3 Maintains agreements with behavioral healthcare providers.

One of the agreements mentioned above needs to be with a behavioral healthcare provider. According to NCQA, a practice needs an agreement if it shares the same facility or campus as mental health professionals, but has separate systems (basic collaboration onsite). Or a practice can use existing internal processes as its agreement if there is partial or full integration of behavioral health care services.

You will need to provide NCQA with one example.

5.B.4 Integrates behavioral healthcare providers within the practice site.

According to NCQA, the integration can be partial (i.e., co-location with some systems in common) or fully (i.e., co-location with all systems shared). You will need to provide materials showing how the behavioral healthcare providers are integrated.

5.B.5 Gives the consultant or specialist the clinical question, the required timing and the type of referral.

All of this information needs to be provided within referrals. NCQA requires a documented process and a report, log, or other means of demonstrating that its process is followed. The report may be system generated or may be based on at least one week (five days) of referrals, with de-identified patient data.

5.B.6 Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan.

Use the Summary of Care Record generated by PCC EHR for this information. Demographic (including insurance) and clinical data is included in this record. If the patient has a documented care plan, it is automatically included within he summary of care record.

NCQA requires a documented process and a report, log, or other means of demonstrating that its process is followed. If the summary of care record is used to meet this factor, provide NCQA with some de-identified examples of this record.

5.B.7 Has the capacity for electronic exchange of key clinical information+ and provides an electronic summary of care record to another provider for more than 50 percent of referrals.

NCQA has stated that in alignment with the Meaningful Use Modified Stage 2 Final Rule, NCQA will accept a report demonstrating provision of electronic care summaries for more than 10 percent of referrals.

Refer to the "Summary of Care (Transmitted Only)" measure results in the "Stage 2" or "Modified Stage 2" version of the Meaningful Use report in PCC EHR. In order to meet this measure, your practice needs to use PCC's Direct Secure Messaging functionality to transmit a summary of care record electronically to another provider.

5.B.8 Tracks referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports. (CRITICAL FACTOR)

Description Example/Screenshot/Documentation Source Date Added
Document describing how to use tasks to track the status of referrals Tracking status of referrals in PCC EHR PCC 07/07/14
Document describing how to followup up on referrals in PCC EHR Following up on referrals in PCC EHR PCC 07/07/14

5.B.9 Documents co-management arrangements in the patient’s medical record.

Description Example/Screenshot/Documentation Source Date Added
Document describing how to use Care Plans to document co-management and agreements with specialists in PCC EHR Using Care Plans to document co-management and agreements in PCC EHR PCC 07/07/14

NCQA will need to review at least three examples.

5.B.10 Asks patients/families about self-referrals and requesting reports from clinicians.

According to NCQA, you should routinely ask patients if they have seen a specialist or are currently receiving care from a specialist and, if so, request a report from the specialist, to be documented in the medical record. This question should be added within each protocol you use (possibly in the intake section) so your staff is prompted to ask and document this during each visit.

NCQA will review a documented process and screenshots demonstrating that you are documenting this information.