2017 - Competency CM-A
Competency A: The practice systematically identifies patients who may benefit from care management
CM 01 (Core): Considers the following when establishing a systematic process and criteria for identifying patients who may benefit from care management (practice must include at least three in its criteria):
The practice defines a protocol to identify patients who may benefit from care management. Specific guidance includes the categories or conditions listed in A–E
- A. Behavioral health conditions
- A diagnosis of a behavioral issue (e.g., visits, medication, treatment or other measures related to behavioral health).
- Psychiatric hospitalizations (e.g., two or more in the past year).
- Substance use treatment.
- A positive screening result from a standardized behavioral health screener (including substance use).
PCC's recaller or EHR Patient List functionality can be used to identify patients based on billed diagnosis (recaller) or active problem list, lab result, or medication (EHR Patient Lists). Also consider using the "Orders by Visit" report in the EHR Report Library to identify patients having a specific mental health screening with a positive result
- B. High cost/high utilization.
- Patients who experience multiple ER visits, hospital readmissions, high total cost of care, unusually high numbers of imaging or lab tests ordered, unusually high number of prescriptions, high-cost medications and number of secondary specialist referrals.
PCC has a custom srs report that will identify patients who had the most visits or charges within a time period. Use this report to identify patients in need of care management based on their high utilization of your services. Contact PCC support to get this report installed on your system.
- C. Poorly controlled or complex conditions.
- Patients with poorly controlled or complex conditions such as, continued abnormally high A1C or blood pressure results, consistent failure to meet treatment goals, multiple comorbid conditions
Consider using PCC EHR Patient Lists to identify patients with high Blood Pressure, high BMI percentile, or particular lab test results.
- D. Social determinants of health.
- Availability of resources such as food and transportation 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
- E. Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff, patient/ family/caregiver.
- Direct identification of patients who might need care management such as, referrals made from health plans, practice staff, patient, family members, or caregivers. Consider establishing a process by which your own staff, patients, or family members can anonymously identify patients that are in need of additional care management.
CM 02 (Core): Monitors the percentage of the total patient population identified through its process and criteria
The practice determines its subset of patients for care management, based on the patient population and the practice’s capacity to provide services. The practice uses the criteria defined in CM 01 to identify patients who fit defined criteria. Patients who fit multiple criteria count once in the numerator.
Consider assigning a "Care Management" flag to patients identified as needing Care Management from CM 01. Then use PCC's recaller report to count the number of unique patients with that flag and divide by the number of active patients (you can also get this from PCC's recaller report). This is the percentage you will need to report for CM02
CM 03 (2 Credits): Applies a comprehensive risk- stratification process for the entire patient panel in order to identify and direct resources appropriately
The practice demonstrates that it can identify patients who are at high risk, or likely to be at high risk, and prioritize their care management to prevent poor outcomes. Practice identifies and directs resources appropriately based on need.