2014 - PCMH4A

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The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of the following:

• Behavioral health conditions
• High cost/high utilization
• Poorly controlled or complex conditions
• Social determinants of health
• Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver

According to NCQA, The intent of the element is that practices use defined criteria to identify true vulnerability—a single criterion, such as cost, may not be an appropriate indicator of need for care management.

The practice considers how its comprehensive health assessment (PCMH 3, Element C) supports establishing criteria and a systematic process for identifying patients for care management.

4.A.1 Behavioral health conditions.

The practice has specific criteria for identifying patients with behavioral conditions for whole-person care planning and management. Criteria are developed from a profile of patient assessments, and may include the following, or a combination of the following:

• A diagnosis of a behavioral issue (e.g., visits, medication, treatment or other measures related to behavioral health).
• Psychiatric hospitalizations (e.g., two or more in the past year).
• Substance use treatment.
• A positive screening result from a standardized behavioral health screener (including substance use).

PCC's recaller or EHR Patient List functionality can be used to identify patients based on billed diagnosis (recaller) or active problem list, lab result, or medication (EHR Patient Lists).

4.A.2 High cost/high utilization.

Refer to PCC's 'utilize' report which is designed to show patients who utilize your services most in terms of number of visits and cost (charges billed). Contact PCC support for assistance with locating and running this report.

4.A.3 Poorly controlled or complex conditions.

Description	Example/Screenshot/Documentation	Source	Date Added

4.A.4 Social determinants of health.

Description	Example/Screenshot/Documentation	Source	Date Added

4.A.5 Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver.

Description	Example/Screenshot/Documentation	Source	Date Added

4.A.6. The practice monitors the percentage of the total patient population identified through its process and criteria. CRITICAL FACTOR)

Description	Example/Screenshot/Documentation	Source	Date Added