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To identify high-risk or complex patients, the practice:

3.B.1 Establishes criteria and a systematic process to identify high risk or complex patients

For this element, you need to document specific criteria considered to be complex or high-risk and a process you would go through to identify patients with these complex or high-risk medical conditions.

NCQA says you may identify children and youth with special health care needs who are defined by the U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) as children “who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services of a type or amount beyond that required generally.” (Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, American Academy of Pediatrics, 3rd Edition, 2008, p. 18.)

Note: A sample of the patients identified as high risk or complex will be included in the medical record review required for Elements C and D, and for PCMH 4, Element A.

Description Example/Screenshot/Documentation Source Date Added
Patients with BMI greater than or equal to the 95th percentile
PCC EHR Patient List with Elevated BMI (>=95th)
PCC EHR Patient Lists 03/25/13
Patients on certain medications. Use PCC EHR Patient Lists restricting by Medication to include patients who were prescribing specific high-risk meds.

3.B.2 Determines the percentage of high risk or complex patients in its population

For this, you just need to report a percentage of your total active patient population who are part of the "high risk" population you identified in 3.B.1.