https://pcmh.pcc.com/api.php?action=feedcontributions&user=Tim&feedformat=atomPCMH - User contributions [en]2024-03-29T06:47:50ZUser contributionsMediaWiki 1.40.1https://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=1001PCC PCMH Resources2021-01-08T16:59:01Z<p>Tim: /* PCC Collaboration with The Verden Group's Patient Centered Solutions */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= Why Get PCMH Recognition? =<br />
<br />
NCQA PCMH Recognition is the most widely-used way to transform primary care practices into medical homes. More than 12,000 practices (with more than 60,000 clinicians) are recognized - about 18 percent of all primary care clinicians.<br />
<br />
Benefits for clinicians include:<br />
*Earn higher reimbursement. More than 50 payers nationwide offer enhanced reimbursement for recognized clinicians or support for practices to become recognized.<br />
*Earn Maintenance of Certification (MOC) credits. Several medical boards award clinicians in NCQA-recognized practices Maintenance of Certification (MOC) credits, reducing the burden on clinicians to take on additional activities.<br />
*Focus on patient care. The PCMH model ensures that team members operate at the highest level of their knowledge, skills, abilities and license, within their assigned roles and responsibilities.<br />
<br />
NCQA Resources<br />
*[http://www.ncqa.org/Portals/0/qpass/NCQA1074-0317_Getting_Started_Toolkit_Web.pdf Toolkit: Getting Started with NCQA PCMH Recognition]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/NCQA1005-1016_PCMH%20Evidence_Web.pdf Evidence Report]<br />
*[http://www.ncqa.org/education-training/pcmh-pcsp Training On-site or On-demand]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/Resources/02012018_Resource_Directory_of_Incentives_for_NCQA_Recognition.pdf Resource Directory of Incentives for NCQA Recognition]<br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide a comprehensive program assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering.<br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC_PrevalidationLOE_6.18.2020_(2).pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC_PrevalidationLOE_6.18.2020_(2).pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/education-training/pcmh-pcsp NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=1000PCC PCMH Resources2020-06-22T15:00:09Z<p>Tim: /* PCC Prevalidation */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= Why Get PCMH Recognition? =<br />
<br />
NCQA PCMH Recognition is the most widely-used way to transform primary care practices into medical homes. More than 12,000 practices (with more than 60,000 clinicians) are recognized - about 18 percent of all primary care clinicians.<br />
<br />
Benefits for clinicians include:<br />
*Earn higher reimbursement. More than 50 payers nationwide offer enhanced reimbursement for recognized clinicians or support for practices to become recognized.<br />
*Earn Maintenance of Certification (MOC) credits. Several medical boards award clinicians in NCQA-recognized practices Maintenance of Certification (MOC) credits, reducing the burden on clinicians to take on additional activities.<br />
*Focus on patient care. The PCMH model ensures that team members operate at the highest level of their knowledge, skills, abilities and license, within their assigned roles and responsibilities.<br />
<br />
NCQA Resources<br />
*[http://www.ncqa.org/Portals/0/qpass/NCQA1074-0317_Getting_Started_Toolkit_Web.pdf Toolkit: Getting Started with NCQA PCMH Recognition]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/NCQA1005-1016_PCMH%20Evidence_Web.pdf Evidence Report]<br />
*[http://www.ncqa.org/education-training/pcmh-pcsp Training On-site or On-demand]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/Resources/02012018_Resource_Directory_of_Incentives_for_NCQA_Recognition.pdf Resource Directory of Incentives for NCQA Recognition]<br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC_PrevalidationLOE_6.18.2020_(2).pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC_PrevalidationLOE_6.18.2020_(2).pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/education-training/pcmh-pcsp NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=File:PCC_PrevalidationLOE_6.18.2020_(2).pdf&diff=999File:PCC PrevalidationLOE 6.18.2020 (2).pdf2020-06-22T14:58:56Z<p>Tim: PCC Prevalidation letter dated 2020</p>
<hr />
<div>== Summary ==<br />
PCC Prevalidation letter dated 2020</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_KM-A&diff=9982017 - Competency KM-A2019-05-03T15:43:28Z<p>Tim: Undo revision 997 by Tim (talk)</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_TC-C << Move to TC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_KM-B >> Move to KM-B]<br />
<br />
= KM 01 (Core): Documents an up-to-date problem list for each patient with current and active diagnoses =<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC MU Report “Stage 1 - Problem List”||[[Media:KM01-ProblemList.png|MU Report Example - Problem List]]||PCC||8/10/17<br />
|}<br />
<br />
= KM 02 (Core): Comprehensive health assessment includes (all items required):=<br />
<br />
*A. Medical history of patient and family.<br />
<br />
Collects patient and family medical history (e.g., history of chronic disease or event [e.g., diabetes, cancer, surgery, hypertension]) for patient and “first-degree” relatives (i.e., who share about 50% of their genes with a specific family member).<br />
<br />
*B. Mental health/substance use history of patient and family.<br />
<br />
Collects patient and family behavioral health history (e.g., schizophrenia, stress, alcohol, prescription drug abuse, illegal drug use, maternal depression).<br />
<br />
*C. Family/social/cultural characteristics.<br />
<br />
Evaluates social and cultural needs, preferences, strengths and limitations. Examples include family/household structure, support systems, and patient/family concerns. Broad consideration should be given to a variety of characteristics (e.g., education level, marital status, unemployment, social support, assigned responsibilities).<br />
<br />
*D. Communication needs.<br />
<br />
Identifies whether a patient has specific communication requirements due to hearing, vision or cognition issues.<br />
<br />
*E. Behaviors affecting health.<br />
<br />
Assesses risky and unhealthy behaviors that go beyond physical activity, alcohol consumption and smoking status and may include nutrition, oral health, dental care, risky sexual behavior and secondhand smoke exposure.<br />
<br />
*F. Social functioning.<br />
<br />
Assesses a patient’s ability to interact with other people in everyday social tasks and to maintain an adequate social life. May include isolation, declining cognition, social anxiety, interpersonal relationships, activities of independent living, social interactions and so on.<br />
<br />
*G. Social determinants of health.<br />
<br />
Collects information on social determinants of health: conditions in a patient’s environment that affect a wide range of health, functioning and quality-of-life outcomes and risks. Examples include availability of resources to meet daily needs; access to educational, economic and job opportunities; public safety, social support; social norms and attitudes; food and housing insecurities; household/environmental risk factors; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation (Healthy People 2020).<br />
<br />
*H. Developmental screening using a standardized tool. (NA for practices with no pediatric population under 30 months of age.)<br />
<br />
For newborns through 3 years of age, uses a standardized tool for periodic developmental screening. If there are no established risk factors or parental concerns, screens are done by 24 months.<br />
<br />
*I. Advance care planning. (NA for pediatric practices.)<br />
<br />
As a pediatric practice, you get credit for this component and can claim "N/A"<br />
<br />
= KM 03 (Core): Conducts depression screenings for adults and adolescents using a standardized tool =<br />
<br />
The documented process includes the practice’s screening process and approach to follow-up for positive screens. The practice reports screening rate and identifies the standardized screening tool.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC CQM Report “Screening for Clinical Depression and Follow-Up Plan”||[[Media:KM03DepressionCQM.png|CQM Report Example]]||PCC||8/11/17<br />
|}<br />
<br />
= KM 04 (1 Credit): Conducts behavioral health screenings and/or assessments using a standardized tool. (Implement two or more.) =<br />
<br />
View the [https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf AAP's list of mental health screening and assessment tools]<br />
<br />
*A. Anxiety.<br />
<br />
The practice conducts screening for the presence of emotional distress and symptoms of anxiety using any validated tool (e.g., GAD-2, GAD-7).<br />
<br />
*B. Alcohol use disorder.<br />
<br />
The American Academy of Pediatrics’ (AAP) Bright Futures recommends clinicians screen all adolescents for alcohol and drug use during all appropriate acute care visits using developmentally appropriate screening tools. (e.g., CRAFFT or Alcohol Screening and Brief Intervention for Youth).<br />
<br />
*C. Substance use disorder.<br />
<br />
Available screening tools may include the Screening, Brief Intervention and Referral to Treatment (SBIRT) tool, CAGE AID or DAST-10 instruments which assess a variety of substance use conditions.<br />
<br />
*D. Pediatric behavioral health screening.<br />
<br />
This may include tools such as the Behavioral Assessment System for Children (BASC).<br />
<br />
*E. Post-traumatic stress disorder.<br />
<br />
*F. Attention deficit/hyperactivity disorder.<br />
<br />
The Vanderbilt Assessment Scale or the DSM V ADHD checklist for adults or children/adolescents are examples of screening tools used to determine if a patient has Attention Deficit/ Hyperactivity Disorder (ADHD).<br />
<br />
*G. Postpartum depression.<br />
<br />
The AAP’s Bright Futures acknowledges that primary care practices that see both infants and their families have a unique opportunity to integrate postpartum depression screening into the well-child care schedule. Validated screening tools may include PHQ-2, PHQ-9 or Edinburgh Postnatal Depression Scale (EPDS) or other validated screening tools, and may be conducted 4–6 weeks postpartum or during the 1-, 2-, 4- or 6-month well-child visits.<br />
<br />
=KM 05 (1 Credit): Assesses oral health needs and provides necessary services during the care visit based on evidence-based guidelines or coordinates with oral health partners=<br />
<br />
The practice conducts patient-specific oral health risk assessments and keeps a list of oral health partners such as dentists, endodontists, oral surgeons and/or periodontists from which to refer.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Monitor Fluoride Varnish rate measure in Dashboard||[[Media:KM05FluorideVarnish.png|Dashboard Fluoride Varnish Rate Example]]||PCC||8/11/17<br />
|}<br />
<br />
=KM 06 (1 Credit): Identifies the predominant conditions and health concerns of the patient population=<br />
<br />
The practice identifies its patients’ most prevalent and important conditions and concerns, through analysis of diagnosis codes or problem lists.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Generate "Predominant Conditions of Your Patient Population" report within PCMH category of EHR Report Library||||PCC||5/3/19<br />
|}<br />
<br />
=KM 07 (2 Credits): Understands social determinants of health for patients, monitors at the population level and implements care interventions based on these data=<br />
<br />
After the practice collects information on social determinants of health, it demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources or other tools to serve the on-going needs of its population. Routine collection of data on social determinants of health (as required in KM 02) is an important step, but the real benefit to the population comes when the practice uses the information to continuously enhance care systems and community connections to systematically address needs.<br />
<br />
= KM 08 (1 Credit): Evaluates patient population demographics/communication preferences/health literacy to tailor development and distribution of patient materials=<br />
<br />
The practice demonstrates an understanding of the patients’ communication needs by utilizing materials and media that are easy for their patient population to understand and use. The practice considers patient demographics such as age, language needs, ethnicity and education when creating materials for its population. The practice may consider how its patients like to receive information (i.e., paper brochure, phone app, text message, e-mail), in addition to the readability of materials (e.g., general literacy and health literacy).<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Store communication preference for patients and generate report||[[Media:KM08CommPreference.png|Example spreadsheet pivot table showing breakdown by communication preference]]||PCC||8/11/17<br />
|}<br />
<br />
'''Contact PCC Client Advocate for assistance with creating this report'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_KM-A&diff=9972017 - Competency KM-A2019-05-03T15:40:15Z<p>Tim: /* KM 08 (1 Credit): Evaluates patient population demographics/communication preferences/health literacy to tailor development and distribution of patient materials */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_TC-C << Move to TC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_KM-B >> Move to KM-B]<br />
<br />
= KM 01 (Core): Documents an up-to-date problem list for each patient with current and active diagnoses =<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC MU Report “Stage 1 - Problem List”||[[Media:KM01-ProblemList.png|MU Report Example - Problem List]]||PCC||8/10/17<br />
|}<br />
<br />
= KM 02 (Core): Comprehensive health assessment includes (all items required):=<br />
<br />
*A. Medical history of patient and family.<br />
<br />
Collects patient and family medical history (e.g., history of chronic disease or event [e.g., diabetes, cancer, surgery, hypertension]) for patient and “first-degree” relatives (i.e., who share about 50% of their genes with a specific family member).<br />
<br />
*B. Mental health/substance use history of patient and family.<br />
<br />
Collects patient and family behavioral health history (e.g., schizophrenia, stress, alcohol, prescription drug abuse, illegal drug use, maternal depression).<br />
<br />
*C. Family/social/cultural characteristics.<br />
<br />
Evaluates social and cultural needs, preferences, strengths and limitations. Examples include family/household structure, support systems, and patient/family concerns. Broad consideration should be given to a variety of characteristics (e.g., education level, marital status, unemployment, social support, assigned responsibilities).<br />
<br />
*D. Communication needs.<br />
<br />
Identifies whether a patient has specific communication requirements due to hearing, vision or cognition issues.<br />
<br />
*E. Behaviors affecting health.<br />
<br />
Assesses risky and unhealthy behaviors that go beyond physical activity, alcohol consumption and smoking status and may include nutrition, oral health, dental care, risky sexual behavior and secondhand smoke exposure.<br />
<br />
*F. Social functioning.<br />
<br />
Assesses a patient’s ability to interact with other people in everyday social tasks and to maintain an adequate social life. May include isolation, declining cognition, social anxiety, interpersonal relationships, activities of independent living, social interactions and so on.<br />
<br />
*G. Social determinants of health.<br />
<br />
Collects information on social determinants of health: conditions in a patient’s environment that affect a wide range of health, functioning and quality-of-life outcomes and risks. Examples include availability of resources to meet daily needs; access to educational, economic and job opportunities; public safety, social support; social norms and attitudes; food and housing insecurities; household/environmental risk factors; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation (Healthy People 2020).<br />
<br />
*H. Developmental screening using a standardized tool. (NA for practices with no pediatric population under 30 months of age.)<br />
<br />
For newborns through 3 years of age, uses a standardized tool for periodic developmental screening. If there are no established risk factors or parental concerns, screens are done by 24 months.<br />
<br />
*I. Advance care planning. (NA for pediatric practices.)<br />
<br />
As a pediatric practice, you get credit for this component and can claim "N/A"<br />
<br />
= KM 03 (Core): Conducts depression screenings for adults and adolescents using a standardized tool =<br />
<br />
The documented process includes the practice’s screening process and approach to follow-up for positive screens. The practice reports screening rate and identifies the standardized screening tool.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC CQM Report “Screening for Clinical Depression and Follow-Up Plan”||[[Media:KM03DepressionCQM.png|CQM Report Example]]||PCC||8/11/17<br />
|}<br />
<br />
= KM 04 (1 Credit): Conducts behavioral health screenings and/or assessments using a standardized tool. (Implement two or more.) =<br />
<br />
View the [https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf AAP's list of mental health screening and assessment tools]<br />
<br />
*A. Anxiety.<br />
<br />
The practice conducts screening for the presence of emotional distress and symptoms of anxiety using any validated tool (e.g., GAD-2, GAD-7).<br />
<br />
*B. Alcohol use disorder.<br />
<br />
The American Academy of Pediatrics’ (AAP) Bright Futures recommends clinicians screen all adolescents for alcohol and drug use during all appropriate acute care visits using developmentally appropriate screening tools. (e.g., CRAFFT or Alcohol Screening and Brief Intervention for Youth).<br />
<br />
*C. Substance use disorder.<br />
<br />
Available screening tools may include the Screening, Brief Intervention and Referral to Treatment (SBIRT) tool, CAGE AID or DAST-10 instruments which assess a variety of substance use conditions.<br />
<br />
*D. Pediatric behavioral health screening.<br />
<br />
This may include tools such as the Behavioral Assessment System for Children (BASC).<br />
<br />
*E. Post-traumatic stress disorder.<br />
<br />
*F. Attention deficit/hyperactivity disorder.<br />
<br />
The Vanderbilt Assessment Scale or the DSM V ADHD checklist for adults or children/adolescents are examples of screening tools used to determine if a patient has Attention Deficit/ Hyperactivity Disorder (ADHD).<br />
<br />
*G. Postpartum depression.<br />
<br />
The AAP’s Bright Futures acknowledges that primary care practices that see both infants and their families have a unique opportunity to integrate postpartum depression screening into the well-child care schedule. Validated screening tools may include PHQ-2, PHQ-9 or Edinburgh Postnatal Depression Scale (EPDS) or other validated screening tools, and may be conducted 4–6 weeks postpartum or during the 1-, 2-, 4- or 6-month well-child visits.<br />
<br />
=KM 05 (1 Credit): Assesses oral health needs and provides necessary services during the care visit based on evidence-based guidelines or coordinates with oral health partners=<br />
<br />
The practice conducts patient-specific oral health risk assessments and keeps a list of oral health partners such as dentists, endodontists, oral surgeons and/or periodontists from which to refer.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Monitor Fluoride Varnish rate measure in Dashboard||[[Media:KM05FluorideVarnish.png|Dashboard Fluoride Varnish Rate Example]]||PCC||8/11/17<br />
|}<br />
<br />
=KM 06 (1 Credit): Identifies the predominant conditions and health concerns of the patient population=<br />
<br />
The practice identifies its patients’ most prevalent and important conditions and concerns, through analysis of diagnosis codes or problem lists.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Generate "Predominant Conditions of Your Patient Population" report within PCMH category of EHR Report Library||||PCC||5/3/19<br />
|}<br />
<br />
=KM 07 (2 Credits): Understands social determinants of health for patients, monitors at the population level and implements care interventions based on these data=<br />
<br />
After the practice collects information on social determinants of health, it demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources or other tools to serve the on-going needs of its population. Routine collection of data on social determinants of health (as required in KM 02) is an important step, but the real benefit to the population comes when the practice uses the information to continuously enhance care systems and community connections to systematically address needs.<br />
<br />
= KM 08 (1 Credit): Evaluates patient population demographics/communication preferences/health literacy to tailor development and distribution of patient materials=<br />
<br />
The practice demonstrates an understanding of the patients’ communication needs by utilizing materials and media that are easy for their patient population to understand and use. The practice considers patient demographics such as age, language needs, ethnicity and education when creating materials for its population. The practice may consider how its patients like to receive information (i.e., paper brochure, phone app, text message, e-mail), in addition to the readability of materials (e.g., general literacy and health literacy).<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Store communication preference for patients and generate "Patient Count and Percentage by Primary Preferred Language" within PCMH category of EHR Report Library||||PCC||5/3/19<br />
|}</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_KM-A&diff=9962017 - Competency KM-A2019-05-03T15:37:50Z<p>Tim: /* KM 06 (1 Credit): Identifies the predominant conditions and health concerns of the patient population */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_TC-C << Move to TC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_KM-B >> Move to KM-B]<br />
<br />
= KM 01 (Core): Documents an up-to-date problem list for each patient with current and active diagnoses =<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC MU Report “Stage 1 - Problem List”||[[Media:KM01-ProblemList.png|MU Report Example - Problem List]]||PCC||8/10/17<br />
|}<br />
<br />
= KM 02 (Core): Comprehensive health assessment includes (all items required):=<br />
<br />
*A. Medical history of patient and family.<br />
<br />
Collects patient and family medical history (e.g., history of chronic disease or event [e.g., diabetes, cancer, surgery, hypertension]) for patient and “first-degree” relatives (i.e., who share about 50% of their genes with a specific family member).<br />
<br />
*B. Mental health/substance use history of patient and family.<br />
<br />
Collects patient and family behavioral health history (e.g., schizophrenia, stress, alcohol, prescription drug abuse, illegal drug use, maternal depression).<br />
<br />
*C. Family/social/cultural characteristics.<br />
<br />
Evaluates social and cultural needs, preferences, strengths and limitations. Examples include family/household structure, support systems, and patient/family concerns. Broad consideration should be given to a variety of characteristics (e.g., education level, marital status, unemployment, social support, assigned responsibilities).<br />
<br />
*D. Communication needs.<br />
<br />
Identifies whether a patient has specific communication requirements due to hearing, vision or cognition issues.<br />
<br />
*E. Behaviors affecting health.<br />
<br />
Assesses risky and unhealthy behaviors that go beyond physical activity, alcohol consumption and smoking status and may include nutrition, oral health, dental care, risky sexual behavior and secondhand smoke exposure.<br />
<br />
*F. Social functioning.<br />
<br />
Assesses a patient’s ability to interact with other people in everyday social tasks and to maintain an adequate social life. May include isolation, declining cognition, social anxiety, interpersonal relationships, activities of independent living, social interactions and so on.<br />
<br />
*G. Social determinants of health.<br />
<br />
Collects information on social determinants of health: conditions in a patient’s environment that affect a wide range of health, functioning and quality-of-life outcomes and risks. Examples include availability of resources to meet daily needs; access to educational, economic and job opportunities; public safety, social support; social norms and attitudes; food and housing insecurities; household/environmental risk factors; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation (Healthy People 2020).<br />
<br />
*H. Developmental screening using a standardized tool. (NA for practices with no pediatric population under 30 months of age.)<br />
<br />
For newborns through 3 years of age, uses a standardized tool for periodic developmental screening. If there are no established risk factors or parental concerns, screens are done by 24 months.<br />
<br />
*I. Advance care planning. (NA for pediatric practices.)<br />
<br />
As a pediatric practice, you get credit for this component and can claim "N/A"<br />
<br />
= KM 03 (Core): Conducts depression screenings for adults and adolescents using a standardized tool =<br />
<br />
The documented process includes the practice’s screening process and approach to follow-up for positive screens. The practice reports screening rate and identifies the standardized screening tool.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC CQM Report “Screening for Clinical Depression and Follow-Up Plan”||[[Media:KM03DepressionCQM.png|CQM Report Example]]||PCC||8/11/17<br />
|}<br />
<br />
= KM 04 (1 Credit): Conducts behavioral health screenings and/or assessments using a standardized tool. (Implement two or more.) =<br />
<br />
View the [https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf AAP's list of mental health screening and assessment tools]<br />
<br />
*A. Anxiety.<br />
<br />
The practice conducts screening for the presence of emotional distress and symptoms of anxiety using any validated tool (e.g., GAD-2, GAD-7).<br />
<br />
*B. Alcohol use disorder.<br />
<br />
The American Academy of Pediatrics’ (AAP) Bright Futures recommends clinicians screen all adolescents for alcohol and drug use during all appropriate acute care visits using developmentally appropriate screening tools. (e.g., CRAFFT or Alcohol Screening and Brief Intervention for Youth).<br />
<br />
*C. Substance use disorder.<br />
<br />
Available screening tools may include the Screening, Brief Intervention and Referral to Treatment (SBIRT) tool, CAGE AID or DAST-10 instruments which assess a variety of substance use conditions.<br />
<br />
*D. Pediatric behavioral health screening.<br />
<br />
This may include tools such as the Behavioral Assessment System for Children (BASC).<br />
<br />
*E. Post-traumatic stress disorder.<br />
<br />
*F. Attention deficit/hyperactivity disorder.<br />
<br />
The Vanderbilt Assessment Scale or the DSM V ADHD checklist for adults or children/adolescents are examples of screening tools used to determine if a patient has Attention Deficit/ Hyperactivity Disorder (ADHD).<br />
<br />
*G. Postpartum depression.<br />
<br />
The AAP’s Bright Futures acknowledges that primary care practices that see both infants and their families have a unique opportunity to integrate postpartum depression screening into the well-child care schedule. Validated screening tools may include PHQ-2, PHQ-9 or Edinburgh Postnatal Depression Scale (EPDS) or other validated screening tools, and may be conducted 4–6 weeks postpartum or during the 1-, 2-, 4- or 6-month well-child visits.<br />
<br />
=KM 05 (1 Credit): Assesses oral health needs and provides necessary services during the care visit based on evidence-based guidelines or coordinates with oral health partners=<br />
<br />
The practice conducts patient-specific oral health risk assessments and keeps a list of oral health partners such as dentists, endodontists, oral surgeons and/or periodontists from which to refer.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Monitor Fluoride Varnish rate measure in Dashboard||[[Media:KM05FluorideVarnish.png|Dashboard Fluoride Varnish Rate Example]]||PCC||8/11/17<br />
|}<br />
<br />
=KM 06 (1 Credit): Identifies the predominant conditions and health concerns of the patient population=<br />
<br />
The practice identifies its patients’ most prevalent and important conditions and concerns, through analysis of diagnosis codes or problem lists.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Generate "Predominant Conditions of Your Patient Population" report within PCMH category of EHR Report Library||||PCC||5/3/19<br />
|}<br />
<br />
=KM 07 (2 Credits): Understands social determinants of health for patients, monitors at the population level and implements care interventions based on these data=<br />
<br />
After the practice collects information on social determinants of health, it demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources or other tools to serve the on-going needs of its population. Routine collection of data on social determinants of health (as required in KM 02) is an important step, but the real benefit to the population comes when the practice uses the information to continuously enhance care systems and community connections to systematically address needs.<br />
<br />
= KM 08 (1 Credit): Evaluates patient population demographics/communication preferences/health literacy to tailor development and distribution of patient materials=<br />
<br />
The practice demonstrates an understanding of the patients’ communication needs by utilizing materials and media that are easy for their patient population to understand and use. The practice considers patient demographics such as age, language needs, ethnicity and education when creating materials for its population. The practice may consider how its patients like to receive information (i.e., paper brochure, phone app, text message, e-mail), in addition to the readability of materials (e.g., general literacy and health literacy).<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Store communication preference for patients and generate report||[[Media:KM08CommPreference.png|Example spreadsheet pivot table showing breakdown by communication preference]]||PCC||8/11/17<br />
|}<br />
<br />
'''Contact PCC Client Advocate for assistance with creating this report'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_KM-A&diff=9952017 - Competency KM-A2019-05-03T15:35:56Z<p>Tim: /* KM 06 (1 Credit): Identifies the predominant conditions and health concerns of the patient population */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_TC-C << Move to TC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_KM-B >> Move to KM-B]<br />
<br />
= KM 01 (Core): Documents an up-to-date problem list for each patient with current and active diagnoses =<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC MU Report “Stage 1 - Problem List”||[[Media:KM01-ProblemList.png|MU Report Example - Problem List]]||PCC||8/10/17<br />
|}<br />
<br />
= KM 02 (Core): Comprehensive health assessment includes (all items required):=<br />
<br />
*A. Medical history of patient and family.<br />
<br />
Collects patient and family medical history (e.g., history of chronic disease or event [e.g., diabetes, cancer, surgery, hypertension]) for patient and “first-degree” relatives (i.e., who share about 50% of their genes with a specific family member).<br />
<br />
*B. Mental health/substance use history of patient and family.<br />
<br />
Collects patient and family behavioral health history (e.g., schizophrenia, stress, alcohol, prescription drug abuse, illegal drug use, maternal depression).<br />
<br />
*C. Family/social/cultural characteristics.<br />
<br />
Evaluates social and cultural needs, preferences, strengths and limitations. Examples include family/household structure, support systems, and patient/family concerns. Broad consideration should be given to a variety of characteristics (e.g., education level, marital status, unemployment, social support, assigned responsibilities).<br />
<br />
*D. Communication needs.<br />
<br />
Identifies whether a patient has specific communication requirements due to hearing, vision or cognition issues.<br />
<br />
*E. Behaviors affecting health.<br />
<br />
Assesses risky and unhealthy behaviors that go beyond physical activity, alcohol consumption and smoking status and may include nutrition, oral health, dental care, risky sexual behavior and secondhand smoke exposure.<br />
<br />
*F. Social functioning.<br />
<br />
Assesses a patient’s ability to interact with other people in everyday social tasks and to maintain an adequate social life. May include isolation, declining cognition, social anxiety, interpersonal relationships, activities of independent living, social interactions and so on.<br />
<br />
*G. Social determinants of health.<br />
<br />
Collects information on social determinants of health: conditions in a patient’s environment that affect a wide range of health, functioning and quality-of-life outcomes and risks. Examples include availability of resources to meet daily needs; access to educational, economic and job opportunities; public safety, social support; social norms and attitudes; food and housing insecurities; household/environmental risk factors; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation (Healthy People 2020).<br />
<br />
*H. Developmental screening using a standardized tool. (NA for practices with no pediatric population under 30 months of age.)<br />
<br />
For newborns through 3 years of age, uses a standardized tool for periodic developmental screening. If there are no established risk factors or parental concerns, screens are done by 24 months.<br />
<br />
*I. Advance care planning. (NA for pediatric practices.)<br />
<br />
As a pediatric practice, you get credit for this component and can claim "N/A"<br />
<br />
= KM 03 (Core): Conducts depression screenings for adults and adolescents using a standardized tool =<br />
<br />
The documented process includes the practice’s screening process and approach to follow-up for positive screens. The practice reports screening rate and identifies the standardized screening tool.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Use PCC CQM Report “Screening for Clinical Depression and Follow-Up Plan”||[[Media:KM03DepressionCQM.png|CQM Report Example]]||PCC||8/11/17<br />
|}<br />
<br />
= KM 04 (1 Credit): Conducts behavioral health screenings and/or assessments using a standardized tool. (Implement two or more.) =<br />
<br />
View the [https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf AAP's list of mental health screening and assessment tools]<br />
<br />
*A. Anxiety.<br />
<br />
The practice conducts screening for the presence of emotional distress and symptoms of anxiety using any validated tool (e.g., GAD-2, GAD-7).<br />
<br />
*B. Alcohol use disorder.<br />
<br />
The American Academy of Pediatrics’ (AAP) Bright Futures recommends clinicians screen all adolescents for alcohol and drug use during all appropriate acute care visits using developmentally appropriate screening tools. (e.g., CRAFFT or Alcohol Screening and Brief Intervention for Youth).<br />
<br />
*C. Substance use disorder.<br />
<br />
Available screening tools may include the Screening, Brief Intervention and Referral to Treatment (SBIRT) tool, CAGE AID or DAST-10 instruments which assess a variety of substance use conditions.<br />
<br />
*D. Pediatric behavioral health screening.<br />
<br />
This may include tools such as the Behavioral Assessment System for Children (BASC).<br />
<br />
*E. Post-traumatic stress disorder.<br />
<br />
*F. Attention deficit/hyperactivity disorder.<br />
<br />
The Vanderbilt Assessment Scale or the DSM V ADHD checklist for adults or children/adolescents are examples of screening tools used to determine if a patient has Attention Deficit/ Hyperactivity Disorder (ADHD).<br />
<br />
*G. Postpartum depression.<br />
<br />
The AAP’s Bright Futures acknowledges that primary care practices that see both infants and their families have a unique opportunity to integrate postpartum depression screening into the well-child care schedule. Validated screening tools may include PHQ-2, PHQ-9 or Edinburgh Postnatal Depression Scale (EPDS) or other validated screening tools, and may be conducted 4–6 weeks postpartum or during the 1-, 2-, 4- or 6-month well-child visits.<br />
<br />
=KM 05 (1 Credit): Assesses oral health needs and provides necessary services during the care visit based on evidence-based guidelines or coordinates with oral health partners=<br />
<br />
The practice conducts patient-specific oral health risk assessments and keeps a list of oral health partners such as dentists, endodontists, oral surgeons and/or periodontists from which to refer.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Monitor Fluoride Varnish rate measure in Dashboard||[[Media:KM05FluorideVarnish.png|Dashboard Fluoride Varnish Rate Example]]||PCC||8/11/17<br />
|}<br />
<br />
=KM 06 (1 Credit): Identifies the predominant conditions and health concerns of the patient population=<br />
<br />
The practice identifies its patients’ most prevalent and important conditions and concerns, through analysis of diagnosis codes or problem lists.<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Generate PCC report showing predominant diagnoses for each provider||[[Media:KM06PredominantICD10.png|Example of custom srs report showing ICD-10 codes used most often by provider]]||PCC||8/11/17<br />
|}<br />
<br />
=KM 07 (2 Credits): Understands social determinants of health for patients, monitors at the population level and implements care interventions based on these data=<br />
<br />
After the practice collects information on social determinants of health, it demonstrates the ability to assess data and address identified gaps using community partnerships, self-management resources or other tools to serve the on-going needs of its population. Routine collection of data on social determinants of health (as required in KM 02) is an important step, but the real benefit to the population comes when the practice uses the information to continuously enhance care systems and community connections to systematically address needs.<br />
<br />
= KM 08 (1 Credit): Evaluates patient population demographics/communication preferences/health literacy to tailor development and distribution of patient materials=<br />
<br />
The practice demonstrates an understanding of the patients’ communication needs by utilizing materials and media that are easy for their patient population to understand and use. The practice considers patient demographics such as age, language needs, ethnicity and education when creating materials for its population. The practice may consider how its patients like to receive information (i.e., paper brochure, phone app, text message, e-mail), in addition to the readability of materials (e.g., general literacy and health literacy).<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Store communication preference for patients and generate report||[[Media:KM08CommPreference.png|Example spreadsheet pivot table showing breakdown by communication preference]]||PCC||8/11/17<br />
|}<br />
<br />
'''Contact PCC Client Advocate for assistance with creating this report'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9942017 - Competency QI-A2019-03-08T01:23:50Z<p>Tim: /* QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type): */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:<br />
* Use of Appropriate Medications for Asthma<br />
* Appropriate Testing for Children With Pharyngitis<br />
* Appropriate Treatment for Children With Upper Respiratory Infection (URI)<br />
* Followup Care for Children Prescribed ADHD Medication<br />
||[http://learn.pcc.com/help/meet-clinical-quality-measures-with-pcc-ehr/ How to Chart for each CQM in PCC EHR]<br />
||PCC<br />
||11/19/18<br />
|-<br />
|Using PCC EHR Report Library Reports '''Chronic Condition Recall''' and '''Patients Overdue for Weight Management''', you can generate measure data for:<br />
* Obesity patient followup<br />
* Patients seen at the office within a week of ER or hospital discharge<br />
||<br />
||<br />
||<br />
|}<br />
<br />
==D. Behavioral health measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using PCC EHR Report Library Reports '''Patient List''' or '''Preventive Care Recall''', you can generate measure data for:<br />
* Patients in need of maternal depression screening<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
<br />
* As it is related to medication reconciliation for care transitions, the measure defined within [http://pcmh.pcc.com/index.php/2017_-_Competency_KM-D#KM_14_.28Core.29:_Reviews_and_reconciles_medications_for_more_than_80_percent_of_patients_received_from_care_transitions PCMH factor KM14] can be used as one care coordination measure:<br />
<br />
'''Reviews and reconciles medications for more than 80 percent of patients received from care transitions.'''<br />
<br />
This can be reported from the "Medication Reconciliation" measure within the "Modified Stage 2" Meaningful Use report in the EHR. You need to meet the 80%<br />
threshold to get credit for factor KM14, but for QI02 documentation you just need to show a numerator, denominator, and time period used for the measure.<br />
You don't need to meet the 80% threshold to get credit for QI02<br />
<br />
* Another care coordination measure that could be used for QI02 is based on the '''Portal message response time report in the EHR Report Library'''. This report will show the response time for portal messages being sent to you by patients. If you export that data to a spreadsheet and calculate average response time for portal messages over a reporting period, this would be a good example of a care coordination measure.<br />
<br />
Other care coordination measures that can be used are related to referral tracking followup and ER followups. <br />
<br />
* NQF also has provided these examples of care coordination measures relevant to pediatrics:<br />
** Reconciled medication list received by discharged patients (inpatient discharge to home/self-care or any other site of care).<br />
** Transition record, with specified elements received by discharged patients (inpatient discharge to home/self-care or any other site of care).<br />
** Timely transmission of transition record (inpatient discharge to home/self-care or any other site of care).<br />
** Transition record, with specified elements received by discharged patients (emergency department discharges to ambulatory care [home/self-care]).<br />
<br />
==B. Measures affecting health care costs.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|PCC eRx can report on utilization measure affecting health care costs such as:<br />
* Utilization of generic vs brand name prescriptions<br />
* Utilization of non-formulary medications<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9932017 - Competency QI-A2019-03-08T01:22:26Z<p>Tim: /* QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type): */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:<br />
* Use of Appropriate Medications for Asthma<br />
* Appropriate Testing for Children With Pharyngitis<br />
* Appropriate Treatment for Children With Upper Respiratory Infection (URI)<br />
* Followup Care for Children Prescribed ADHD Medication<br />
||[http://learn.pcc.com/help/meet-clinical-quality-measures-with-pcc-ehr/ How to Chart for each CQM in PCC EHR]<br />
||PCC<br />
||11/19/18<br />
|-<br />
|Using PCC EHR Report Library Reports '''Chronic Condition Recall''' and '''Patients Overdue for Weight Management''', you can generate measure data for:<br />
* Obesity patient followup<br />
* Patients seen at the office within a week of ER or hospital discharge<br />
||<br />
||<br />
||<br />
|}<br />
<br />
==D. Behavioral health measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using PCC EHR Report Library Reports '''Patient List''' or '''Preventive Care Recall''', you can generate measure data for:<br />
* Patients in need of maternal depression screening<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
<br />
* As it is related to medication reconciliation for care transitions, the measure defined within [http://pcmh.pcc.com/index.php/2017_-_Competency_KM-D#KM_14_.28Core.29:_Reviews_and_reconciles_medications_for_more_than_80_percent_of_patients_received_from_care_transitions PCMH factor KM14] can be used as one care coordination measure:<br />
<br />
'''Reviews and reconciles medications for more than 80 percent of patients received from care transitions.'''<br />
<br />
This can be reported from the "Medication Reconciliation" measure within the "Modified Stage 2" Meaningful Use report in the EHR. You need to meet the 80%<br />
threshold to get credit for factor KM14, but for QI02 documentation you just need to show a numerator, denominator, and time period used for the measure.<br />
You don't need to meet the 80% threshold to get credit for QI02<br />
<br />
* Another care coordination measure that could be used for QI02 is based on the '''Portal message response time report in the EHR Report Library'''. This report will show the response time for portal messages being sent to you by patients. If you export that data to a spreadsheet and calculate average response time for portal messages over a reporting period, this would be a good example of a care coordination measure.<br />
<br />
Other care coordination measures that can be used are related to referral tracking followup and ER followups. <br />
<br />
* NQF also has provided these examples of care coordination measures relevant to pediatrics:<br />
** Reconciled medication list received by discharged patients (inpatient discharge to home/self-care or any other site of care).<br />
** Transition record, with specified elements received by discharged patients (inpatient discharge to home/self-care or any other site of care).<br />
** Timely transmission of transition record (inpatient discharge to home/self-care or any other site of care).<br />
** Transition record, with specified elements received by discharged patients (emergency department discharges to ambulatory care [home/self-care]).<br />
<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9922017 - Competency QI-A2019-03-08T01:21:24Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:<br />
* Use of Appropriate Medications for Asthma<br />
* Appropriate Testing for Children With Pharyngitis<br />
* Appropriate Treatment for Children With Upper Respiratory Infection (URI)<br />
* Followup Care for Children Prescribed ADHD Medication<br />
||[http://learn.pcc.com/help/meet-clinical-quality-measures-with-pcc-ehr/ How to Chart for each CQM in PCC EHR]<br />
||PCC<br />
||11/19/18<br />
|-<br />
|Using PCC EHR Report Library Reports '''Chronic Condition Recall''' and '''Patients Overdue for Weight Management''', you can generate measure data for:<br />
* Obesity patient followup<br />
* Patients seen at the office within a week of ER or hospital discharge<br />
||<br />
||<br />
||<br />
|}<br />
<br />
==D. Behavioral health measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using PCC EHR Report Library Reports '''Patient List''' or '''Preventive Care Recall''', you can generate measure data for:<br />
* Patients in need of maternal depression screening<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
<br />
* As it is related to medication reconciliation for care transitions, the measure defined within [http://pcmh.pcc.com/index.php/2017_-_Competency_KM-D#KM_14_.28Core.29:_Reviews_and_reconciles_medications_for_more_than_80_percent_of_patients_received_from_care_transitions PCMH factor KM14] can be used as one care coordination measure:<br />
<br />
'''Reviews and reconciles medications for more than 80 percent of patients received from care transitions.'''<br />
<br />
This can be reported from the "Medication Reconciliation" measure within the "Modified Stage 2" Meaningful Use report in the EHR. You need to meet the 80%<br />
threshold to get credit for factor KM14, but for QI02 documentation you just need to show a numerator, denominator, and time period used for the measure.<br />
You don't need to meet the 80% threshold to get credit for QI02<br />
<br />
* Another care coordination measure that could be used for QI02 is based on the '''Portal message response time report in the EHR Report Library'''. This report will show the response time for portal messages being sent to you by patients. If you export that data to a spreadsheet and calculate average response time for portal messages over a reporting period, this would be a good example of a care coordination measure.<br />
<br />
Other care coordination measures that can be used are related to referral tracking followup and ER followups. <br />
<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9912017 - Competency QI-A2018-11-19T19:16:07Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:<br />
* Use of Appropriate Medications for Asthma<br />
* Appropriate Testing for Children With Pharyngitis<br />
* Appropriate Treatment for Children With Upper Respiratory Infection (URI)<br />
* Followup Care for Children Prescribed ADHD Medication<br />
||[http://learn.pcc.com/help/meet-clinical-quality-measures-with-pcc-ehr/ How to Chart for each CQM in PCC EHR]<br />
||PCC<br />
||11/19/18<br />
|-<br />
|Using PCC EHR Report Library Reports '''Chronic Condition Recall''' and '''Patients Overdue for Weight Management''', you can generate measure data for:<br />
* Obesity patient followup<br />
* Patients seen at the office within a week of ER or hospital discharge<br />
||<br />
||<br />
||<br />
|}<br />
<br />
==D. Behavioral health measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using PCC EHR Report Library Reports '''Patient List''' or '''Preventive Care Recall''', you can generate measure data for:<br />
* Patients in need of maternal depression screening<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9902017 - Competency QI-A2018-11-19T19:14:07Z<p>Tim: /* D. Behavioral health measures. */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:<br />
* Use of Appropriate Medications for Asthma<br />
* Appropriate Testing for Children With Pharyngitis<br />
* Appropriate Treatment for Children With Upper Respiratory Infection (URI)<br />
* Followup Care for Children Prescribed ADHD Medication<br />
||[http://learn.pcc.com/help/meet-clinical-quality-measures-with-pcc-ehr/ How to Chart for each CQM in PCC EHR]<br />
||PCC<br />
||11/19/18<br />
|-<br />
|Using PCC EHR Report Library Reports '''Chronic Condition Recall''' and '''Patients Overdue for Weight Management''', you can generate measure data for:<br />
* Obesity patient followup<br />
* Patients seen at the office within a week of ER or hospital discharge<br />
||<br />
||<br />
||<br />
|}<br />
<br />
==D. Behavioral health measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|Using Dashboard you can generate measure data for behavioral health measures including:<br />
* ADHD Patient Followup<br />
* Depression Screening Rates - Adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9892017 - Competency QI-A2018-11-19T19:12:03Z<p>Tim: /* C. Chronic or acute care clinical measures. */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:<br />
* Use of Appropriate Medications for Asthma<br />
* Appropriate Testing for Children With Pharyngitis<br />
* Appropriate Treatment for Children With Upper Respiratory Infection (URI)<br />
* Followup Care for Children Prescribed ADHD Medication<br />
||[http://learn.pcc.com/help/meet-clinical-quality-measures-with-pcc-ehr/ How to Chart for each CQM in PCC EHR]<br />
||PCC<br />
||11/19/18<br />
|-<br />
|Using PCC EHR Report Library Reports '''Chronic Condition Recall''' and '''Patients Overdue for Weight Management''', you can generate measure data for:<br />
* Obesity patient followup<br />
* Patients seen at the office within a week of ER or hospital discharge<br />
||<br />
||<br />
||<br />
|}<br />
<br />
==D. Behavioral health measures.==<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9882017 - Competency QI-A2018-11-19T19:11:40Z<p>Tim: /* C. Chronic or acute care clinical measures. */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using CQM reports in PCC EHR, you can generate measure data for chronic or acute care clinical measures including:<br />
* Use of Appropriate Medications for Asthma<br />
* Appropriate Testing for Children With Pharyngitis<br />
* Appropriate Treatment for Children With Upper Respiratory Infection (URI)<br />
* Followup Care for Children Prescribed ADHD Medication<br />
||[http://learn.pcc.com/help/meet-clinical-quality-measures-with-pcc-ehr/|How to Chart for each CQM in PCC EHR]<br />
||PCC<br />
||11/19/18<br />
|-<br />
|Using PCC EHR Report Library Reports '''Chronic Condition Recall''' and '''Patients Overdue for Weight Management''', you can generate measure data for:<br />
* Obesity patient followup<br />
* Patients seen at the office within a week of ER or hospital discharge<br />
||<br />
||<br />
||<br />
|}<br />
<br />
==D. Behavioral health measures.==<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9872017 - Competency QI-A2018-11-19T19:00:55Z<p>Tim: /* B. Other preventive care measures. */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
||<br />
||<br />
||<br />
|-<br />
|Using "Patient List" and "Preventive Care Recall" tools within the EHR Report Library, you can now generate measure data for other preventive measures such as:<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||<br />
||<br />
||<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
<br />
==D. Behavioral health measures.==<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9862017 - Competency QI-A2018-11-19T18:50:51Z<p>Tim: /* B. Other preventive care measures. */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard, recaller, and other reporting tools you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants<br />
* Fluoride Varnish Rate<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||[[media:6A.1.pdf|Using PCC reporting tools to track preventive care measures ]]<br />
||PCC<br />
||07/07/14<br />
|-<br />
|Various Reports and Samples. These reports are generated from Partner, the PCC Dashboard, or the PCC EHR ||[[media:PCMH_6_A_1-4.pdf|Examples ]]||TPC|| 03/25/13<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
<br />
==D. Behavioral health measures.==<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9852017 - Competency QI-A2018-11-19T18:49:14Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
<br />
The Dashboard includes data for the following immunization measures:<br />
<br />
* Immunization Rates - Adolescents (HPV, TdaP, and Meningococcal combined)<br />
* Immunization Rates - HPV<br />
* Immunization Rates - Influenza<br />
* Immunization Rates - Meningococcal<br />
* Immunization Rates - Patients 2 Years Old<br />
* Immunization Rates - Tdap<br />
<br />
Data is updated monthly, and trend data is also reported.<br />
<br />
==B. Other preventive care measures.==<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using Dashboard, recaller, and other reporting tools you can generate measure data for preventive measures including:<br />
* Well Visit Rates (for various age ranges)<br />
* Developmental Screening Rates for Infants and Adolescents<br />
* Fluoride Varnish Rate<br />
* Preschool vision screening<br />
* Preschool hearing screening<br />
* Tobacco or alcohol abuse counseling for adolescents<br />
||[[media:6A.1.pdf|Using PCC reporting tools to track preventive care measures ]]<br />
||PCC<br />
||07/07/14<br />
|-<br />
|Various Reports and Samples. These reports are generated from Partner, the PCC Dashboard, or the PCC EHR ||[[media:PCMH_6_A_1-4.pdf|Examples ]]||TPC|| 03/25/13<br />
|-<br />
|}<br />
<br />
==C. Chronic or acute care clinical measures.==<br />
<br />
<br />
==D. Behavioral health measures.==<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-C&diff=9842017 - Competency CC-C2018-11-13T16:46:38Z<p>Tim: /* CC 20 (1 Credit): Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care) */</p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-B << Move to CC-B]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-A >> Move to QI-A]<br />
<br />
Competency C: The practice connects with health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.<br />
<br />
=CC 14 (Core): Systematically identifies patients with unplanned hospital admissions and emergency department visits=<br />
<br />
=CC 15 (Core): Shares clinical information with admitting hospitals and emergency departments=<br />
<br />
=CC 16 (Core): Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit=<br />
<br />
=CC 17 (1 Credit): Systematic ability to coordinate with acute care settings after office hours through access to current patient information=<br />
<br />
=CC 18 (1 Credit): Exchanges patient information with the hospital during a patient’s hospitalization=<br />
<br />
=CC 19 (1 Credit): Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities=<br />
<br />
=CC 20 (1 Credit): Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care)=<br />
<br />
{| border = "1"<br />
! style="background:#8facd9; width:40%;" |'''Description'''<br />
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''<br />
! style="background:#8facd9; width:20%;" |'''Source'''<br />
! style="background:#8facd9; width:20%;" |'''Date Added'''<br />
|-<br />
|Using PCC EHR Care Plan functionality for organizing materials and information in preparation for transitioning a patient from pediatric care to adult care.<br />
||[[media:5C.6.pdf|Using PCC EHR Care Plans for transitions of care ]]||PCC|| 07/07/14<br />
|<br />
|-<br />
|}<br />
<br />
=CC 21 (Maximum 3 Credits): Demonstrates electronic exchange of information with external entities, agencies and registries (May select one or more)=<br />
<br />
==A. Regional health information organization or other health information exchange source that enhances the practice’s ability to manage complex patients. (1 Credit)==<br />
==B. Immunization registries or immunization information systems. (1 Credit)==<br />
==C. Summary of care record to another provider or care facility for care transitions. (1 Credit)==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CM-B&diff=9832017 - Competency CM-B2018-10-03T15:06:52Z<p>Tim: /* CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management */</p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-A >> Move to CC-A]<br />
<br />
Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.<br />
<br />
=CM 04 (Core): Establishes a person-centered care plan for patients identified for care management=<br />
<br />
The practice has a process to consistently develop patient care plans for the patients identified for care management. To ensure that a care plan is meaningful, realistic and actionable, the practice involves the patient in the plan’s development, which includes discussions about goals (e.g., patient function/life style, goal feasibility and barriers) and considers patient preferences.<br />
<br />
The care plan incorporates a problem list, expected outcome/ prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed. The care plan may also address community and/or social services.<br />
<br />
The practice updates the care plan at relevant visits. A relevant visit addresses an aspect of care that could affect progress toward meeting existing goals or require modification of an existing goal.<br />
<br />
Use NCQA's Record Review Workbook to choose a sample of relevant patients identified (and flagged) from CM 01 and check for the relevant items.<br />
<br />
'''Use [http://learn.pcc.com/help/care-plan/ PCC's Care Plan tracking functionality] for patients identified for care management. Some practices may prefer to create a special protocol to add to visits for patients identified as needing care management. The benefit of using PCC's integrated care plan functionality is that the plan is tracked discretely within the patient's medical summary and is easily accessible at any visit.'''<br />
<br />
'''Use the "Care Plans by Date" report in PCC's EHR Report Library to identify patients with a Care Plan'''<br />
<br />
=CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management=<br />
<br />
The practice provides the patient’s written care plan to the patient/family/caregiver. This can also be provided to the patient electronically. The practice may tailor the written care plan to accommodate the patient’s health literacy and language preference. (i.e., the patient version may use different words of formats from the version used by the practice team)<br />
<br />
Report or Record Review Workbook and patient examples are required. <br />
<br />
'''Use the EHR Component Builder to create a new Handout Order called "Written care plan provided". Add this order to your visit protocols and check it off when a written care plan is provided to patients during a visit. This will allow you to track whether the written care plan was provided.'''<br />
<br />
'''Patients now have access to their care plan within their patient portal account. If the patient has a care plan and a portal account, their care plan is accessible electronically via the patient portal which will count toward meeting this component'''<br />
<br />
=CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans=<br />
<br />
The practice works with patients/families/caregivers to incorporate patient preferences and functional lifestyle goals in the care plan. <br />
<br />
Report or Record Review Workbook and patient examples are required. <br />
<br />
=CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans=<br />
<br />
Addressing barriers supports successful completion of the goals stated in the care plan. Barriers may include physical, emotional or social barriers<br />
<br />
Report or Record Review Workbook and patient examples are required.<br />
<br />
=CM 08 (1 Credit): Includes a self-management plan in individual care plans=<br />
<br />
The practice works with patients/families/ caregivers to develop self-management instructions to manage day-to-day challenges of a complex condition. The plan may include best practices or supports for managing issues related to a complex condition identified in the care plan.<br />
<br />
Report or Record Review Workbook and patient examples are required.<br />
<br />
=CM 09 (1 Credit): Care plan is integrated and accessible across settings of care=<br />
<br />
Sharing the care plan supports its implementation across all settings that address the patient’s care needs. The practice makes the care plan accessible across external care settings. It may be integrated into a shared electronic medical record, information exchange or other cross-organization sharing tool or arrangement.<br />
<br />
Documented process and evidence of implementation is required.<br />
<br />
'''The patient Care Plan is accessible to patients within the Patient Portal. Consider using that as an example of providing accessibility of the Care Plan to patients in any clinical setting'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9822017 - Competency QI-A2018-06-14T20:46:35Z<p>Tim: </p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
==B. Other preventive care measures.==<br />
==C. Chronic or acute care clinical measures.==<br />
==D. Behavioral health measures.==<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==<br />
<br />
=QI 05 (1 Credit): Assesses health disparities using performance data stratified for vulnerable populations (must choose one from each section):=<br />
==A. Clinical quality.==<br />
==B. Patient experience==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9812017 - Competency QI-A2018-06-14T20:45:37Z<p>Tim: </p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=QI 01 (Core): Monitors at least five clinical quality measures across the four categories (must monitor at least one measure of each type):=<br />
<br />
==A. Immunization measures.==<br />
==B. Other preventive care measures.==<br />
==C. Chronic or acute care clinical measures.==<br />
==D. Behavioral health measures.==<br />
<br />
=QI 02 (Core): Monitors at least two measures of resource stewardship (must monitor at least 1 measure of each type):=<br />
<br />
==A. Measures related to care coordination.==<br />
==B. Measures affecting health care costs.==<br />
<br />
=QI 03 (Core): Assesses performance on availability of major appointment types to meet patient needs and preferences for access.=<br />
<br />
=QI 04 (Core): Monitors patient experience through:==<br />
<br />
==A. Quantitative data. Conducts a survey (using any instrument) to evaluate patient/family/caregiver experiences across at least three dimensions such as:==<br />
*Access<br />
*Communication.<br />
*Coordination.<br />
*Whole-person care, self-management support and comprehensiveness.<br />
<br />
==B. Qualitative data. Obtains feedback from patients/families/caregivers through qualitative means.==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-B&diff=9802017 - Competency CC-B2018-06-14T20:42:20Z<p>Tim: </p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-A << Move to CC-A]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C >> Move to CC-C]<br />
<br />
Competency B: The practice provides important information in referrals to specialists and tracks referrals until the report is received<br />
<br />
=CC 04 (Core): The practice systematically manages referrals by=<br />
<br />
==A. Giving the consultant or specialist the clinical question, the required timing and the type of referral==<br />
<br />
<br />
==B. Giving the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan==<br />
<br />
==C. Tracking referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports==<br />
<br />
=CC 05 (2 Credits): Uses clinical protocols to determine when a referral to a specialist is necessary=<br />
<br />
=CC 06 (1 Credit): Identifies the specialists/specialty types frequently used by the practice=<br />
<br />
=CC 07 (2 Credits): Considers available performance information on consultants/specialists when making referrals=<br />
<br />
=CC 08 (1 Credit): Works with nonbehavioral healthcare specialists to whom the practice frequently refers to set expectations for information sharing and patient care=<br />
<br />
=CC 09 (2 Credits): Works with behavioral healthcare providers to whom the practice frequently refers to set expectations for information sharing and patient care=<br />
<br />
=CC 10 (2 Credits): Integrates behavioral healthcare providers into the care delivery system of the practice site=<br />
<br />
=CC 11 (1 Credit): Monitors the timeliness and quality of the referral response=<br />
<br />
=CC 12 (1 Credit): Documents co-management arrangements in the patient’s medical record=<br />
<br />
=CC 13 (2 Credits): Engages with patients regarding cost implications of treatment options=</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-C&diff=9792017 - Competency CC-C2018-06-14T20:41:48Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-B << Move to CC-B]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-A >> Move to QI-A]<br />
<br />
Competency C: The practice connects with health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.<br />
<br />
=CC 14 (Core): Systematically identifies patients with unplanned hospital admissions and emergency department visits=<br />
<br />
=CC 15 (Core): Shares clinical information with admitting hospitals and emergency departments=<br />
<br />
=CC 16 (Core): Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit=<br />
<br />
=CC 17 (1 Credit): Systematic ability to coordinate with acute care settings after office hours through access to current patient information=<br />
<br />
=CC 18 (1 Credit): Exchanges patient information with the hospital during a patient’s hospitalization=<br />
<br />
=CC 19 (1 Credit): Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities=<br />
<br />
=CC 20 (1 Credit): Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care)=<br />
<br />
=CC 21 (Maximum 3 Credits): Demonstrates electronic exchange of information with external entities, agencies and registries (May select one or more)=<br />
<br />
==A. Regional health information organization or other health information exchange source that enhances the practice’s ability to manage complex patients. (1 Credit)==<br />
==B. Immunization registries or immunization information systems. (1 Credit)==<br />
==C. Summary of care record to another provider or care facility for care transitions. (1 Credit)==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_QI-A&diff=9782017 - Competency QI-A2018-06-14T20:40:52Z<p>Tim: Created page with "[http://pcmh.pcc.com/index.php/2017_Main Table of Contents] [http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C] [http://pcmh.pcc.com/index.php/2017_-_Comp..."</p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C << Move to CC-C]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_QI-B >> Move to QI-B]<br />
<br />
Competency A: The practice measures to understand current performance and to identify opportunities for improvement<br />
<br />
=CC 14 (Core): Systematically identifies patients with unplanned hospital admissions and emergency department visits=</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-C&diff=9772017 - Competency CC-C2018-06-14T20:37:36Z<p>Tim: Created page with "[http://pcmh.pcc.com/index.php/2017_Main Table of Contents] [http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B] [http://pcmh.pcc.com/index.php/2017_-_Comp..."</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C >> Move to CC-C]<br />
<br />
Competency C: The practice connects with health care facilities to support patient safety throughout care transitions. The practice receives and shares necessary patient treatment information to coordinate comprehensive patient care.<br />
<br />
=CC 14 (Core): Systematically identifies patients with unplanned hospital admissions and emergency department visits=<br />
<br />
=CC 15 (Core): Shares clinical information with admitting hospitals and emergency departments=<br />
<br />
=CC 16 (Core): Contacts patients/families/caregivers for follow-up care, if needed, within an appropriate period following a hospital admission or emergency department visit=<br />
<br />
=CC 17 (1 Credit): Systematic ability to coordinate with acute care settings after office hours through access to current patient information=<br />
<br />
=CC 18 (1 Credit): Exchanges patient information with the hospital during a patient’s hospitalization=<br />
<br />
=CC 19 (1 Credit): Implements a process to consistently obtain patient discharge summaries from the hospital and other facilities=<br />
<br />
=CC 20 (1 Credit): Collaborates with the patient/family/caregiver to develop/implement a written care plan for complex patients transitioning into/out of the practice (e.g., from pediatric care to adult care)=<br />
<br />
=CC 21 (Maximum 3 Credits): Demonstrates electronic exchange of information with external entities, agencies and registries (May select one or more)=<br />
<br />
==A. Regional health information organization or other health information exchange source that enhances the practice’s ability to manage complex patients. (1 Credit)==<br />
==B. Immunization registries or immunization information systems. (1 Credit)==<br />
==C. Summary of care record to another provider or care facility for care transitions. (1 Credit)==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-B&diff=9762017 - Competency CC-B2018-06-14T20:33:50Z<p>Tim: Created page with "[http://pcmh.pcc.com/index.php/2017_Main Table of Contents] [http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A] [http://pcmh.pcc.com/index.php/2017_-_Comp..."</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-C >> Move to CC-C]<br />
<br />
Competency B: The practice provides important information in referrals to specialists and tracks referrals until the report is received<br />
<br />
=CC 04 (Core): The practice systematically manages referrals by=<br />
<br />
==A. Giving the consultant or specialist the clinical question, the required timing and the type of referral==<br />
<br />
<br />
==B. Giving the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan==<br />
<br />
==C. Tracking referrals until the consultant or specialist’s report is available, flagging and following up on overdue reports==<br />
<br />
=CC 05 (2 Credits): Uses clinical protocols to determine when a referral to a specialist is necessary=<br />
<br />
=CC 06 (1 Credit): Identifies the specialists/specialty types frequently used by the practice=<br />
<br />
=CC 07 (2 Credits): Considers available performance information on consultants/specialists when making referrals=<br />
<br />
=CC 08 (1 Credit): Works with nonbehavioral healthcare specialists to whom the practice frequently refers to set expectations for information sharing and patient care=<br />
<br />
=CC 09 (2 Credits): Works with behavioral healthcare providers to whom the practice frequently refers to set expectations for information sharing and patient care=<br />
<br />
=CC 10 (2 Credits): Integrates behavioral healthcare providers into the care delivery system of the practice site=<br />
<br />
=CC 11 (1 Credit): Monitors the timeliness and quality of the referral response=<br />
<br />
=CC 12 (1 Credit): Documents co-management arrangements in the patient’s medical record=<br />
<br />
=CC 13 (2 Credits): Engages with patients regarding cost implications of treatment options=</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-A&diff=9752017 - Competency CC-A2018-06-14T20:18:53Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-B >> Move to CC-B]<br />
<br />
Competency A: The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result<br />
<br />
=CC 01 (Core): The practice systematically manages lab and imaging tests by=<br />
<br />
==A. Tracking lab tests until results are available, flagging and following up on overdue results==<br />
<br />
The practice tracks lab tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the lab (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==B. Tracking imaging tests until results are available, flagging and following up on overdue results.==<br />
<br />
The practice tracks imaging tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the diagnostic center (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==C. Flagging abnormal lab results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of lab tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==D. Flagging abnormal imaging results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of imaging tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==E. Notifying patients/families/caregivers of normal lab and imaging test results.==<br />
==F. Notifying patients/families/caregivers of abnormal lab and imaging test results.==<br />
<br />
The practice provides timely notification to patients about test results (normal and abnormal). Filing the report in the medical record for discussion during a scheduled office visit does not meet the requirement.<br />
<br />
=CC 02 (1 Credit): Follows up with the inpatient facility about newborn hearing and blood-spot screening.=<br />
<br />
The practice follows up with the hospital or state health department if it does not receive screening results. '''Documented process and evidence of implementation is required'''<br />
<br />
=CC 03 (2 Credits): Uses clinical protocols to determine when imaging and lab tests are necessary.=<br />
<br />
Redundant or inappropriate use of imaging or lab tests leads to unnecessary costs and risks and does not enhance patient outcomes. The practice has established clinical protocols, based on evidence-based guidelines, to determine when imaging and lab tests are necessary. The practice may implement clinical decision supports to ensure that protocols are used (e.g., embedded in order entry system). <br />
<br />
Evidence of implementation is required and you must have examples of clinical decision support related to both imaging '''and''' lab tests. Clinical decision support must be based on evidence-based-guidelines and you need to list the specific guidelines you are using. <br />
<br />
'''Consider using Bright Futures as evidence-based guidelines within your well visit protocols and lead or chlamydia screening lab test orders based on age. For imaging tests, consider using chest x-ray for pneumonia, ultrasound for appendicitis and echocardiogram for heart murmur. These could be imaging standing orders displayed within certain protocols. Be sure to refer to specific evidence based guidelines when using those imaging orders.'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_Main&diff=9742017 Main2018-05-29T17:37:11Z<p>Tim: </p>
<hr />
<div>This wiki serves as an informal repository of PCMH documentation related to the 2017 PCMH Standards released in March 2017. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
{| style="float: right; border:2px solid #616F7C;background-color:whitesmoke;padding:2px;width:30%;margin: 0 auto 1em auto;"<br />
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<br />
The 2017 Standards are broken down into six concepts that align with the principles of primary care. Within each concept are competencies which are meant to organize the criteria within each concept area. Criteria are the individual structures, functions and activities that indicate a practice is operating as a medical home.<br />
<br />
To achieve recognition under the new PCMH program, practices must:<br />
<br />
* Meet all core criteria <br />
* Earn 25 credits in elective criteria across 5 of 6 concepts. <br />
<br />
This ensures a minimum set of capabilities and gives practices the flexibility to focus on activities that not only mean the most to their patient population, but are feasible to accomplish with regard to their resources and the resources of their community.<br />
<br />
==Team-Based Care and Practice Organization (TC)==<br />
<br />
The practice provides continuity of care, communicates roles and responsibilities of the medical home to patients/families/caregivers, and organizes and trains staff to work to the top of their license and provide effective team-based care.<br />
<br />
===[[2017 - Competency TC-A|Competency A (TC01 - TC05) - The practice is committed to transforming the practice into a sustainable medical home]]=== <br />
<br />
===[[2017 - Competency TC-B|Competency B (TC06 - TC09) - Communication among staff is organized to ensure that patient care is coordinated, safe and effective]]===<br />
<br />
===[[2017 - Competency TC-C|Competency C (TC10) - The practice communicates and engages patients on expectations and their role in the medical home model of care]]===<br />
<br />
==Knowing and Managing Your Patients (KM)==<br />
<br />
The practice captures and analyzes information about the patients and community it serves and uses the information to deliver evidence-based care that supports population needs and provision of culturally and linguistically appropriate services.<br />
<br />
===[[2017 - Competency KM-A|Competency A (KM01 - KM08) - Practice routinely collects comprehensive data on patients to understand background and health risks of patients]]===<br />
<br />
===[[2017 - Competency KM-B|Competency B (KM09 - KM11) - The practice seeks to meet the needs of a diverse patient population by understanding the population’s unique characteristics and language needs]]===<br />
<br />
===[[2017 - Competency KM-C|Competency C (KM12 - KM13) - The practice proactively addresses the care needs of the patient population to ensure needs are met]]===<br />
<br />
===[[2017 - Competency KM-D|Competency D (KM14 - KM19) - The practice addresses medication safety and adherence by providing information to the patient and establishing processes for medication documentation, reconciliation and assessment of barriers]]===<br />
<br />
===[[2017 - Competency KM-E|Competency E (KM20) - The practice incorporates evidence- based clinical decision support across a variety of conditions to ensure effective and efficient care is provided to patients]]===<br />
<br />
===[[2017 - Competency KM-F|Competency F (KM21 - KM28) - The practice identifies/ considers and establishes connections to community resources to collaborate and direct patients to needed support]]===<br />
<br />
==Patient-Centered Access and Continuity (AC)==<br />
The PCMH model expects continuity of care. Patients/families/caregivers have 24/7 access to clinical advice and appropriate care facilitated by their designated clinician/care team and supported by access to their medical record. The practice considers the needs and preferences of the patient population when establishing and updating standards for access.<br />
<br />
===[[2017 - Competency AC-A|Competency A (AC01 - AC09) - The practice seeks to enhance access by providing appointments and clinical advice based on patients’ needs]]===<br />
<br />
===[[2017 - Competency AC-B|Competency B (AC10 - AC14) - Practices support continuity through empanelment and systematic access to the patient’s medical record]]===<br />
<br />
==Care Management and Support (CM)==<br />
The practice identifies patient needs at the individual and population levels to effectively plan, manage and coordinate patient care in partnership with patients/families/caregivers. Emphasis is placed on supporting patients at highest risk.<br />
<br />
===[[2017 - Competency CM-A|Competency A (CM01 - CM03) - The practice systematically identifies patients who may benefit from care management]]===<br />
<br />
===[[2017 - Competency CM-B|Competency B (CM04 - CM09) - For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart]]===<br />
<br />
==Care Coordination and Care Transitions (CC)==<br />
The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.<br />
<br />
===[[2017 - Competency CC-A|Competency A (CC01 - CC03) - The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result]]===<br />
<br />
===[[2017 - Competency CC-B|Competency B (CC04 - CC13) - The practice provides important information in referrals to specialists and tracks referrals until the report is received]]===<br />
<br />
===[[2017 - Competency CC-C|Competency C (CC14 - CC21) - The practice connects with health care facilities to support patient safety throughout care transitions]]===<br />
<br />
==Performance Measurement and Quality Improvement (QI))==<br />
The practice systematically tracks tests, referrals and care transitions to achieve high quality care coordination, lower costs, improve patient safety and ensure effective communication with specialists and other providers in the medical neighborhood.<br />
<br />
===[[2017 - Competency QI-A|Competency A (QI01 - QI07) - The practice measures to understand current performance and to identify opportunities for improvement]]===<br />
<br />
===[[2017 - Competency QI-B|Competency B (QI08 - QI14) - The practice evaluates its performance against goals or benchmarks and uses the results to prioritize and implement improvement strategies]]===<br />
<br />
===[[2017 - Competency QI-C|Competency C (QI15 - QI19) - The practice is accountable for performance. The practice shares performance data with the practice, patients and/or publicly for the measures and patient populations identified in the previous section]]===</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=973PCC PCMH Resources2018-05-21T17:00:29Z<p>Tim: /* Other Resources */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= Why Get PCMH Recognition? =<br />
<br />
NCQA PCMH Recognition is the most widely-used way to transform primary care practices into medical homes. More than 12,000 practices (with more than 60,000 clinicians) are recognized - about 18 percent of all primary care clinicians.<br />
<br />
Benefits for clinicians include:<br />
*Earn higher reimbursement. More than 50 payers nationwide offer enhanced reimbursement for recognized clinicians or support for practices to become recognized.<br />
*Earn Maintenance of Certification (MOC) credits. Several medical boards award clinicians in NCQA-recognized practices Maintenance of Certification (MOC) credits, reducing the burden on clinicians to take on additional activities.<br />
*Focus on patient care. The PCMH model ensures that team members operate at the highest level of their knowledge, skills, abilities and license, within their assigned roles and responsibilities.<br />
<br />
NCQA Resources<br />
*[http://www.ncqa.org/Portals/0/qpass/NCQA1074-0317_Getting_Started_Toolkit_Web.pdf Toolkit: Getting Started with NCQA PCMH Recognition]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/NCQA1005-1016_PCMH%20Evidence_Web.pdf Evidence Report]<br />
*[http://www.ncqa.org/education-training/pcmh-pcsp Training On-site or On-demand]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/Resources/02012018_Resource_Directory_of_Incentives_for_NCQA_Recognition.pdf Resource Directory of Incentives for NCQA Recognition]<br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/education-training/pcmh-pcsp NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=972PCC PCMH Resources2018-05-21T16:59:28Z<p>Tim: </p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= Why Get PCMH Recognition? =<br />
<br />
NCQA PCMH Recognition is the most widely-used way to transform primary care practices into medical homes. More than 12,000 practices (with more than 60,000 clinicians) are recognized - about 18 percent of all primary care clinicians.<br />
<br />
Benefits for clinicians include:<br />
*Earn higher reimbursement. More than 50 payers nationwide offer enhanced reimbursement for recognized clinicians or support for practices to become recognized.<br />
*Earn Maintenance of Certification (MOC) credits. Several medical boards award clinicians in NCQA-recognized practices Maintenance of Certification (MOC) credits, reducing the burden on clinicians to take on additional activities.<br />
*Focus on patient care. The PCMH model ensures that team members operate at the highest level of their knowledge, skills, abilities and license, within their assigned roles and responsibilities.<br />
<br />
NCQA Resources<br />
*[http://www.ncqa.org/Portals/0/qpass/NCQA1074-0317_Getting_Started_Toolkit_Web.pdf Toolkit: Getting Started with NCQA PCMH Recognition]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/NCQA1005-1016_PCMH%20Evidence_Web.pdf Evidence Report]<br />
*[http://www.ncqa.org/education-training/pcmh-pcsp Training On-site or On-demand]<br />
*[http://www.ncqa.org/Portals/0/Programs/Recognition/Resources/02012018_Resource_Directory_of_Incentives_for_NCQA_Recognition.pdf Resource Directory of Incentives for NCQA Recognition]<br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=971PCC PCMH Resources2018-03-20T19:34:45Z<p>Tim: /* PCC Prevalidation */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=File:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf&diff=970File:PCC-PCMH 2017 Prevalidation Letter of Credit Approval v17 final Revised 3.20.18.pdf2018-03-20T19:34:08Z<p>Tim: PCC Prevalidation letter</p>
<hr />
<div>PCC Prevalidation letter</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=968PCC PCMH Resources2018-03-20T19:31:29Z<p>Tim: /* PCC Prevalidation */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_Revised_3.20.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=966PCC PCMH Resources2018-03-16T21:07:36Z<p>Tim: /* PCC Prevalidation */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=965PCC PCMH Resources2018-03-16T21:07:26Z<p>Tim: /* PCC Prevalidation */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
#*Click “My Evaluations”<br />
#*Hover over Action and select “Organization Dashboard”<br />
#*Select “Transfer Credits” button<br />
#*On the “Select Program” screen, pick “Vendor”<br />
#*Select the applicable practice site(s)<br />
#*Using the evidence component, upload the Letter of Product Implementation<br />
#*Click the “Submit for Review” button<br />
#Step 4: Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=964PCC PCMH Resources2018-03-16T21:07:04Z<p>Tim: /* PCC Prevalidation */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Log-In to QPASS and complete the following steps:<br />
*Click “My Evaluations”<br />
*Hover over Action and select “Organization Dashboard”<br />
*Select “Transfer Credits” button<br />
*On the “Select Program” screen, pick “Vendor”<br />
*Select the applicable practice site(s)<br />
*Using the evidence component, upload the Letter of Product Implementation<br />
*Click the “Submit for Review” button<br />
#Step 4: Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=963PCC PCMH Resources2018-03-16T21:06:37Z<p>Tim: </p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. As documented in the [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]], each PCC client practice that wishes to apply for NCQA PCMH 2017 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
#Step 1: Download the NCQA-issued [[media:PCC-PCMH_2017_Prevalidation_Letter_of_Credit_Approval_v17_final_3.7.18.pdf|PCMH 2017 Letter of Credit Approval/Transfer Credit Summary]]<br />
#Step 2: Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
#Step 3: Log-In to QPASS and complete the following steps:<br />
*Click “My Evaluations”<br />
*Hover over Action and select “Organization Dashboard”<br />
*Select “Transfer Credits” button<br />
*On the “Select Program” screen, pick “Vendor”<br />
*Select the applicable practice site(s)<br />
*Using the evidence component, upload the Letter of Product Implementation<br />
*Click the “Submit for Review” button<br />
#Step 4: Receive approval from your NCQA Representative. Once your transfer credit is approved, all eligible criteria with transfer credit will be marked as “met.”<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=961PCC PCMH Resources2018-03-16T20:58:38Z<p>Tim: /* PCC Prevalidation */</p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
As of 03/07/2018, practices utilizing PCC can benefit from reduced documentation for criteria designated as “partially met criteria” and have criteria designated as “fully met criteria” marked as “met” in full. <br />
<br />
As documented in the [http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMHPrevalidationProgram/ForPractices.aspx Step-by-Step Guide for Client Practices], each PCC client practice that wishes to apply for NCQA PCMH 2014 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
* Step 1: Download the NCQA-issued [[media:PCC_PCMH_2014_transfer_credit_table_5.28.15.pdf|PCC Prevalidation Summary Approval Table]] and [[media: PCMH_2014_PCC_Letter_of_Product_Autocredit_Approval_1.22.16_JSR.pdf|NCQA Letter of Product Autocredit Approval]] necessary for submission for NCQA Recognition. <br />
* Step 2: Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
* Step 3: Complete an application and enter into required agreements for the NCQA Recognition program.<br />
* Step 4: Upload the vendor Prevalidation Summary Approval Table, a copy of the NCQA Letter of Product Autocredit Approval and Product Implementation Letter from PCC into the “Organizational Background” section of the ISS Survey Tool.<br />
* Step 5: For all factors that you wish to claim autocredit, enter the “Attestation Statement” into the associated factor’s “notes” field.<br />
* Step 6: Submit the survey tool.<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=960PCC PCMH Resources2018-03-16T20:47:40Z<p>Tim: </p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2017 PCMH Standards =<br />
<br />
NCQA has redesigned PCMH Recognition. The redesigned program includes ongoing, sustained recognition status with Annual Reporting instead of a 3-year recognition cycle. NCQA based the redesign on feedback from practices, policy makers, payers and other stakeholders. The program is more manageable, while continuing to concentrate on performance and quality improvement. It also reduces paperwork and increases practice interaction with NCQA. With the redesigned process came [http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh/getting-recognized/documents new 2017 standards] that were released in April, 2017. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2017_Main the 2017 PCMH Standards] in this wiki to provide quick reference to the 2017 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
Practices using PCC are able to automatically transfer up to '''7.5 auto credit points''' towards the 85 total points needed to achieve NCQA Level 3 Medical Home status based on 2014 standards. Using PCC's software tools and providing the necessary documentation and reporting to NCQA, clients have the ability to achieve an additional '''51.5 points''' toward PCMH recognition.<br />
<br />
As documented in the [http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMHPrevalidationProgram/ForPractices.aspx Step-by-Step Guide for Client Practices], each PCC client practice that wishes to apply for NCQA PCMH 2014 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
* Step 1: Download the NCQA-issued [[media:PCC_PCMH_2014_transfer_credit_table_5.28.15.pdf|PCC Prevalidation Summary Approval Table]] and [[media: PCMH_2014_PCC_Letter_of_Product_Autocredit_Approval_1.22.16_JSR.pdf|NCQA Letter of Product Autocredit Approval]] necessary for submission for NCQA Recognition. <br />
* Step 2: Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
* Step 3: Complete an application and enter into required agreements for the NCQA Recognition program.<br />
* Step 4: Upload the vendor Prevalidation Summary Approval Table, a copy of the NCQA Letter of Product Autocredit Approval and Product Implementation Letter from PCC into the “Organizational Background” section of the ISS Survey Tool.<br />
* Step 5: For all factors that you wish to claim autocredit, enter the “Attestation Statement” into the associated factor’s “notes” field.<br />
* Step 6: Submit the survey tool.<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=PCC_PCMH_Resources&diff=959PCC PCMH Resources2018-03-16T20:41:31Z<p>Tim: </p>
<hr />
<div><br />
This wiki serves as an informal repository of PCMH documentation related to NCQA's 2017 Standards. Some of the content here comes from PCC clients who have generously allowed us to use their material. Nothing in this wiki is official PCC documentation and should be used at your own risk.<br />
<br />
[http://pcmh.pcc.com/index.php/2017_Main PCC's Resources for 2017 PCMH Standards]<br />
<br />
[http://pcmh.pcc.com/index.php/2014_Main PCC's Resources for 2014 PCMH Standards] <span style="color:red">(Outdated as of October, 2017)</span><br />
<br />
= PCC Collaboration with The Verden Group's Patient Centered Solutions =<br />
<br />
[http://www.theverdengroup.com/our-services/patient-centered-solutions-services The Verden Group’s Patient Centered Solutions (PCS)] has collaborated with PCC to provide [[media:PCC-PCS_CLIENT_PROGRAM.pdf|a comprehensive program]] assisting PCC clients in achieving NCQA's PCMH 2014 Recognition. Contact PCC for more details on this offering. <br />
<br />
= 2014 PCMH Standards =<br />
<br />
In March 2014, NCQA released a set of [http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources.aspx#PCMH%20(2014) new standards], and have since made frequent updates. The latest version of these standards along with a survey tool can now be downloaded from [http://store.ncqa.org/index.php/recognition/patient-centered-medical-home-pcmh.html NCQA's web site]. <br />
<br />
PCC has organized [http://pcmh.pcc.com/index.php/2014_Main the 2014 PCMH Standards] in this wiki to provide quick reference to the 2014 standards themselves and, where applicable, documentation showing how PCC functionality applies to individual PCMH factors. In some cases, PCC clients have also generously allowed us to reference their material.<br />
<br />
= PCC Prevalidation =<br />
<br />
Practices using PCC are able to automatically transfer up to '''7.5 auto credit points''' towards the 85 total points needed to achieve NCQA Level 3 Medical Home status based on 2014 standards. Using PCC's software tools and providing the necessary documentation and reporting to NCQA, clients have the ability to achieve an additional '''51.5 points''' toward PCMH recognition.<br />
<br />
As documented in the [http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMHPrevalidationProgram/ForPractices.aspx Step-by-Step Guide for Client Practices], each PCC client practice that wishes to apply for NCQA PCMH 2014 Recognition will need to complete the following steps to use PCC's prevalidated status:<br />
<br />
* Step 1: Download the NCQA-issued [[media:PCC_PCMH_2014_transfer_credit_table_5.28.15.pdf|PCC Prevalidation Summary Approval Table]] and [[media: PCMH_2014_PCC_Letter_of_Product_Autocredit_Approval_1.22.16_JSR.pdf|NCQA Letter of Product Autocredit Approval]] necessary for submission for NCQA Recognition. <br />
* Step 2: Contact PCC to get a Letter of Product Implementation indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at your practice.<br />
* Step 3: Complete an application and enter into required agreements for the NCQA Recognition program.<br />
* Step 4: Upload the vendor Prevalidation Summary Approval Table, a copy of the NCQA Letter of Product Autocredit Approval and Product Implementation Letter from PCC into the “Organizational Background” section of the ISS Survey Tool.<br />
* Step 5: For all factors that you wish to claim autocredit, enter the “Attestation Statement” into the associated factor’s “notes” field.<br />
* Step 6: Submit the survey tool.<br />
<br />
= Other Resources =<br />
<br />
[http://pcmh.pcc.com/index.php/2011_Main PCC's Resources for previous 2011 PCMH Standards]<br />
<br />
[[media:Chart_Review_Rubrics_for_3C,_3D,_4A.pdf|Chart Review Rubrics for 3C, 3D, and 4A]] courtesy of Plateau Pediatrics in TN<br />
<br />
[[media:MU-Crosswalk-new.pdf|Crosswalk of Meaningful Use components to 2014 PCMH standards]]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/OtherPCMHResources/FAQsforPediatricPractices.aspx FAQ for pediatric practices related to 2011 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/NCQAPCMHPCSPRecognitionProgramPricing.aspx NCQA's Pricing and Fee Schedule for PCMH Recognition]<br />
<br />
[http://www.ncqa.org/Portals/0/Programs/Recognition/PCMH/8_PCMH_Recognition_2014_Appendix_6_Summary_of_Updates_to_PCMH_2014.pdf NCQA Clarifications/Corrections on 2014 PCMH Standards]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2011PCMH2014Crosswalk.aspx NCQA's PCMH 2011–PCMH 2014 Crosswalk]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA's 2014 PCMH Content and Scoring Summary]<br />
<br />
[http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH/PCMH2014ContentandScoringSummary.aspx NCQA PCMH 2014: Behind the Enhancements] free webinar download<br />
<br />
[http://www.ncqa.org/programs/recognition/relevant-to-all-recognition/recognition-training/recorded-trainings NCQA's recorded PCMH recognition training]</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-A&diff=9582017 - Competency CC-A2018-02-14T21:37:43Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-B >> Move to CC-B]<br />
<br />
Competency A: The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result<br />
<br />
=CC 01 (Core): The practice systematically manages lab and imaging tests by=<br />
<br />
==A. Tracking lab tests until results are available, flagging and following up on overdue results==<br />
<br />
The practice tracks lab tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the lab (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==B. Tracking imaging tests until results are available, flagging and following up on overdue results.==<br />
<br />
The practice tracks imaging tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the diagnostic center (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==C. Flagging abnormal lab results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of lab tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==D. Flagging abnormal imaging results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of imaging tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==E. Notifying patients/families/caregivers of normal lab and imaging test results.==<br />
==F. Notifying patients/families/caregivers of abnormal lab and imaging test results.==<br />
<br />
The practice provides timely notification to patients about test results (normal and abnormal). Filing the report in the medical record for discussion during a scheduled office visit does not meet the requirement.<br />
<br />
=CC 02 (1 Credit): Follows up with the inpatient facility about newborn hearing and blood-spot screening.=<br />
<br />
The practice follows up with the hospital or state health department if it does not receive screening results. '''Documented process and evidence of implementation is required'''<br />
<br />
=CC 03 (2 Credits): Uses clinical protocols to determine when imaging and lab tests are necessary.=<br />
<br />
Redundant or inappropriate use of imaging or lab tests leads to unnecessary costs and risks and does not enhance patient outcomes. The practice has established clinical protocols, based on evidence-based guidelines, to determine when imaging and lab tests are necessary. The practice may implement clinical decision supports to ensure that protocols are used (e.g., embedded in order entry system). '''Evidence of implementation is required'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-A&diff=9572017 - Competency CC-A2018-02-14T21:34:48Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-B >> Move to CC-B]<br />
<br />
Competency A: The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result<br />
<br />
=CC 01 (Core): The practice systematically manages lab and imaging tests by=<br />
<br />
==A. Tracking lab tests until results are available, flagging and following up on overdue results==<br />
<br />
The practice tracks lab tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the lab (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==B. Tracking imaging tests until results are available, flagging and following up on overdue results.==<br />
<br />
The practice tracks imaging tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the diagnostic center (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==C. Flagging abnormal lab results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of lab tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==D. Flagging abnormal imaging results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of imaging tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==E. Notifying patients/families/caregivers of normal lab and imaging test results.==<br />
==F. Notifying patients/families/caregivers of abnormal lab and imaging test results.==<br />
<br />
The practice provides timely notification to patients about test results (normal and abnormal). Filing the report in the medical record for discussion during a scheduled office visit does not meet the requirement.<br />
<br />
=CC 02 (1 Credit): Follows up with the inpatient facility about newborn hearing and blood-spot screening.=<br />
<br />
The practice follows up with the hospital or state health department if it does not receive screening results. '''Documented process and evidence of implementation is required'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-A&diff=9562017 - Competency CC-A2018-02-14T21:27:08Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-B >> Move to CC-B]<br />
<br />
Competency A: The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result<br />
<br />
=CC 01 (Core): The practice systematically manages lab and imaging tests by=<br />
<br />
==A. Tracking lab tests until results are available, flagging and following up on overdue results==<br />
<br />
The practice tracks lab tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the lab (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==B. Tracking imaging tests until results are available, flagging and following up on overdue results.==<br />
<br />
The practice tracks imaging tests from the time they are ordered until results are available, and flags test results that have not been made available. The flag may be an icon that automatically appears in the electronic system or a manual tracking system with a timely surveillance process. The practice follows up with the diagnostic center (and the patient, if necessary) to determine why results are overdue, and documents follow-up efforts until reports are received.<br />
<br />
==C. Flagging abnormal lab results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of lab tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==D. Flagging abnormal imaging results, bringing them to the attention of the clinician.==<br />
<br />
Abnormal results of imaging tests are flagged and brought to the attention of the clinician, to ensure timely follow-up with the patient/family/caregiver<br />
<br />
==E. Notifying patients/families/caregivers of normal lab and imaging test results.==<br />
==F. Notifying patients/families/caregivers of abnormal lab and imaging test results.==<br />
<br />
The practice provides timely notification to patients about test results (normal and abnormal). Filing the report in the medical record for discussion during a scheduled office visit does not meet the requirement.</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CC-A&diff=9552017 - Competency CC-A2018-02-14T21:10:37Z<p>Tim: Created page with "[http://pcmh.pcc.com/index.php/2017_Main Table of Contents] [http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B] [http://pcmh.pcc.com/index.php/2017_-_Comp..."</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B << Move to CM-B]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-B >> Move to CC-B]<br />
<br />
Competency A: The practice effectively tracks and manages laboratory and imaging tests important for patient care and informs patients of the result<br />
<br />
=CC 01 (Core): The practice systematically manages lab and imaging tests by=<br />
<br />
==A. Tracking lab tests until results are available, flagging and following up on overdue results==</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CM-B&diff=9542017 - Competency CM-B2018-02-06T16:19:12Z<p>Tim: /* CM 09 (1 Credit): Care plan is integrated and accessible across settings of care */</p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-A >> Move to CC-A]<br />
<br />
Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.<br />
<br />
=CM 04 (Core): Establishes a person-centered care plan for patients identified for care management=<br />
<br />
The practice has a process to consistently develop patient care plans for the patients identified for care management. To ensure that a care plan is meaningful, realistic and actionable, the practice involves the patient in the plan’s development, which includes discussions about goals (e.g., patient function/life style, goal feasibility and barriers) and considers patient preferences.<br />
<br />
The care plan incorporates a problem list, expected outcome/ prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed. The care plan may also address community and/or social services.<br />
<br />
The practice updates the care plan at relevant visits. A relevant visit addresses an aspect of care that could affect progress toward meeting existing goals or require modification of an existing goal.<br />
<br />
Use NCQA's Record Review Workbook to choose a sample of relevant patients identified (and flagged) from CM 01 and check for the relevant items.<br />
<br />
'''Use [http://learn.pcc.com/help/care-plan/ PCC's Care Plan tracking functionality] for patients identified for care management. Some practices may prefer to create a special protocol to add to visits for patients identified as needing care management. The benefit of using PCC's integrated care plan functionality is that the plan is tracked discretely within the patient's medical summary and is easily accessible at any visit.'''<br />
<br />
'''Use the "Care Plans by Date" report in PCC's EHR Report Library to identify patients with a Care Plan'''<br />
<br />
=CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management=<br />
<br />
The practice provides the patient’s written care plan to the patient/family/caregiver. The practice may tailor the written care plan to accommodate the patient’s health literacy and language preference. (i.e., the patient version may use different words of formats from the version used by the practice team)<br />
<br />
Report or Record Review Workbook and patient examples are required. <br />
<br />
'''Use the EHR Component Builder to create a new Handout Order called "Written care plan provided". Add this order to your visit protocols and check it off when a written care plan is provided to patients during a visit. This will allow you to track whether the written care plan was provided.'''<br />
<br />
=CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans=<br />
<br />
The practice works with patients/families/caregivers to incorporate patient preferences and functional lifestyle goals in the care plan. <br />
<br />
Report or Record Review Workbook and patient examples are required. <br />
<br />
=CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans=<br />
<br />
Addressing barriers supports successful completion of the goals stated in the care plan. Barriers may include physical, emotional or social barriers<br />
<br />
Report or Record Review Workbook and patient examples are required.<br />
<br />
=CM 08 (1 Credit): Includes a self-management plan in individual care plans=<br />
<br />
The practice works with patients/families/ caregivers to develop self-management instructions to manage day-to-day challenges of a complex condition. The plan may include best practices or supports for managing issues related to a complex condition identified in the care plan.<br />
<br />
Report or Record Review Workbook and patient examples are required.<br />
<br />
=CM 09 (1 Credit): Care plan is integrated and accessible across settings of care=<br />
<br />
Sharing the care plan supports its implementation across all settings that address the patient’s care needs. The practice makes the care plan accessible across external care settings. It may be integrated into a shared electronic medical record, information exchange or other cross-organization sharing tool or arrangement.<br />
<br />
Documented process and evidence of implementation is required.<br />
<br />
'''The patient Care Plan is accessible to patients within the Patient Portal. Consider using that as an example of providing accessibility of the Care Plan to patients in any clinical setting'''</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CM-B&diff=9532017 - Competency CM-B2018-02-06T16:18:53Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-A >> Move to CC-A]<br />
<br />
Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.<br />
<br />
=CM 04 (Core): Establishes a person-centered care plan for patients identified for care management=<br />
<br />
The practice has a process to consistently develop patient care plans for the patients identified for care management. To ensure that a care plan is meaningful, realistic and actionable, the practice involves the patient in the plan’s development, which includes discussions about goals (e.g., patient function/life style, goal feasibility and barriers) and considers patient preferences.<br />
<br />
The care plan incorporates a problem list, expected outcome/ prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed. The care plan may also address community and/or social services.<br />
<br />
The practice updates the care plan at relevant visits. A relevant visit addresses an aspect of care that could affect progress toward meeting existing goals or require modification of an existing goal.<br />
<br />
Use NCQA's Record Review Workbook to choose a sample of relevant patients identified (and flagged) from CM 01 and check for the relevant items.<br />
<br />
'''Use [http://learn.pcc.com/help/care-plan/ PCC's Care Plan tracking functionality] for patients identified for care management. Some practices may prefer to create a special protocol to add to visits for patients identified as needing care management. The benefit of using PCC's integrated care plan functionality is that the plan is tracked discretely within the patient's medical summary and is easily accessible at any visit.'''<br />
<br />
'''Use the "Care Plans by Date" report in PCC's EHR Report Library to identify patients with a Care Plan'''<br />
<br />
=CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management=<br />
<br />
The practice provides the patient’s written care plan to the patient/family/caregiver. The practice may tailor the written care plan to accommodate the patient’s health literacy and language preference. (i.e., the patient version may use different words of formats from the version used by the practice team)<br />
<br />
Report or Record Review Workbook and patient examples are required. <br />
<br />
'''Use the EHR Component Builder to create a new Handout Order called "Written care plan provided". Add this order to your visit protocols and check it off when a written care plan is provided to patients during a visit. This will allow you to track whether the written care plan was provided.'''<br />
<br />
=CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans=<br />
<br />
The practice works with patients/families/caregivers to incorporate patient preferences and functional lifestyle goals in the care plan. <br />
<br />
Report or Record Review Workbook and patient examples are required. <br />
<br />
=CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans=<br />
<br />
Addressing barriers supports successful completion of the goals stated in the care plan. Barriers may include physical, emotional or social barriers<br />
<br />
Report or Record Review Workbook and patient examples are required.<br />
<br />
=CM 08 (1 Credit): Includes a self-management plan in individual care plans=<br />
<br />
The practice works with patients/families/ caregivers to develop self-management instructions to manage day-to-day challenges of a complex condition. The plan may include best practices or supports for managing issues related to a complex condition identified in the care plan.<br />
<br />
Report or Record Review Workbook and patient examples are required.<br />
<br />
=CM 09 (1 Credit): Care plan is integrated and accessible across settings of care=<br />
<br />
Sharing the care plan supports its implementation across all settings that address the patient’s care needs. The practice makes the care plan accessible across external care settings. It may be integrated into a shared electronic medical record, information exchange or other cross-organization sharing tool or arrangement.<br />
<br />
'''The patient Care Plan is accessible to patients within the Patient Portal. Consider using that as an example of providing accessibility of the Care Plan to patients in any clinical setting'''<br />
<br />
Documented process and evidence of implementation is required.</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CM-B&diff=9522017 - Competency CM-B2018-02-06T15:51:51Z<p>Tim: </p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-A >> Move to CC-A]<br />
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Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.<br />
<br />
=CM 04 (Core): Establishes a person-centered care plan for patients identified for care management=<br />
<br />
The practice has a process to consistently develop patient care plans for the patients identified for care management. To ensure that a care plan is meaningful, realistic and actionable, the practice involves the patient in the plan’s development, which includes discussions about goals (e.g., patient function/life style, goal feasibility and barriers) and considers patient preferences.<br />
<br />
The care plan incorporates a problem list, expected outcome/ prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed. The care plan may also address community and/or social services.<br />
<br />
The practice updates the care plan at relevant visits. A relevant visit addresses an aspect of care that could affect progress toward meeting existing goals or require modification of an existing goal.<br />
<br />
Use NCQA's Record Review Workbook to choose a sample of relevant patients identified (and flagged) from CM 01 and check for the relevant items.<br />
<br />
'''Use [http://learn.pcc.com/help/care-plan/ PCC's Care Plan tracking functionality] for patients identified for care management. Some practices may prefer to create a special protocol to add to visits for patients identified as needing care management. The benefit of using PCC's integrated care plan functionality is that the plan is tracked discretely within the patient's medical summary and is easily accessible at any visit.'''<br />
<br />
'''Use the "Care Plans by Date" report in PCC's EHR Report Library to identify patients with a Care Plan'''<br />
<br />
=CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management=<br />
<br />
=CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans=<br />
<br />
=CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans=<br />
<br />
=CM 08 (1 Credit): Includes a self-management plan in individual care plans=<br />
<br />
=CM 09 (1 Credit): Care plan is integrated and accessible across settings of care=</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CM-A&diff=9512017 - Competency CM-A2018-02-06T15:51:34Z<p>Tim: </p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_AC-B << Move to AC-B]<br />
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[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-B >> Move to CM-B]<br />
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Competency A: The practice systematically identifies patients who may benefit from care management<br />
<br />
=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):=<br />
<br />
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<br />
<br />
*A. Behavioral health conditions<br />
**A diagnosis of a behavioral issue (e.g., visits, medication, treatment or other measures related to behavioral health).<br />
**Psychiatric hospitalizations (e.g., two or more in the past year).<br />
**Substance use treatment.<br />
**A positive screening result from a standardized behavioral health screener (including substance use).<br />
<br />
'''PCC's [http://learn.pcc.com/help/quickstart-recalling-patients/ recaller] or [http://learn.pcc.com/help/patient-lists/ 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'''<br />
<br />
*B. High cost/high utilization.<br />
**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.<br />
<br />
'''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.'''<br />
<br />
*C. Poorly controlled or complex conditions.<br />
**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<br />
<br />
'''Consider using PCC EHR Patient Lists to identify patients with high Blood Pressure, high BMI percentile, or particular lab test results.'''<br />
<br />
*D. Social determinants of health.<br />
**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<br />
<br />
*E. Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff, patient/ family/caregiver.<br />
**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.<br />
<br />
=CM 02 (Core): Monitors the percentage of the total patient population identified through its process and criteria=<br />
<br />
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. <br />
<br />
'''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'''<br />
<br />
=CM 03 (2 Credits): Applies a comprehensive risk- stratification process for the entire patient panel in order to identify and direct resources appropriately=<br />
<br />
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.</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CM-B&diff=9502017 - Competency CM-B2018-02-06T15:49:36Z<p>Tim: </p>
<hr />
<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-A >> Move to CC-A]<br />
<br />
Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.<br />
<br />
Refer to [http://learn.pcc.com/help/care-plan/ PCC's Care Plan tracking functionality] when working to meet these factors.<br />
<br />
=CM 04 (Core): Establishes a person-centered care plan for patients identified for care management=<br />
<br />
The practice has a process to consistently develop patient care plans for the patients identified for care management. To ensure that a care plan is meaningful, realistic and actionable, the practice involves the patient in the plan’s development, which includes discussions about goals (e.g., patient function/life style, goal feasibility and barriers) and considers patient preferences.<br />
<br />
The care plan incorporates a problem list, expected outcome/ prognosis, treatment goals, medication management and a schedule to review and revise the plan, as needed. The care plan may also address community and/or social services.<br />
<br />
The practice updates the care plan at relevant visits. A relevant visit addresses an aspect of care that could affect progress toward meeting existing goals or require modification of an existing goal.<br />
<br />
Use NCQA's Record Review Workbook to choose a sample of relevant patients identified (and flagged) from CM 01 and check for the relevant items.<br />
<br />
'''Use [http://learn.pcc.com/help/care-plan/ PCC's Care Plan tracking functionality] for patients identified for care management. Some practices may prefer to create a special protocol to add to visits for patients identified as needing care management. The benefit of using PCC's integrated care plan functionality is that the plan is tracked discretely within the patient's medical summary and is easily accessible at any visit.'''<br />
<br />
'''Use the "Care Plans by Date" report in PCC's EHR Report Library to identify patients with a Care Plan'''<br />
<br />
=CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management=<br />
<br />
=CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans=<br />
<br />
=CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans=<br />
<br />
=CM 08 (1 Credit): Includes a self-management plan in individual care plans=<br />
<br />
=CM 09 (1 Credit): Care plan is integrated and accessible across settings of care=</div>Timhttps://pcmh.pcc.com/index.php?title=2017_-_Competency_CM-B&diff=9492017 - Competency CM-B2018-02-06T15:37:48Z<p>Tim: Created page with "[http://pcmh.pcc.com/index.php/2017_Main Table of Contents] [http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A] [http://pcmh.pcc.com/index.php/2017_-_Comp..."</p>
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<div>[http://pcmh.pcc.com/index.php/2017_Main Table of Contents]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CM-A << Move to CM-A]<br />
<br />
[http://pcmh.pcc.com/index.php/2017_-_Competency_CC-A >> Move to CC-A]<br />
<br />
Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.<br />
<br />
=CM 04 (Core): Establishes a person-centered care plan for patients identified for care management=<br />
<br />
=CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management=<br />
<br />
=CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans=<br />
<br />
=CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans=<br />
<br />
=CM 08 (1 Credit): Includes a self-management plan in individual care plans=<br />
<br />
=CM 09 (1 Credit): Care plan is integrated and accessible across settings of care=</div>Tim