Criterion for Team-Based Care (TC) Core vs. Elective Evidence Type Eligible TC01 - Designated clinician lead for PCMH transformation process Core Details about clinician lead AND Yes Details about PCMH manager Yes TC02 - Defines practice org structure and responsibilities/skills Core structure overview AND Yes Description of staff roles, skills, and responsibilities Yes TC03 - Involved in external PCMH activities (federal/state initiatives, HIE, RHIO, etc.) Elective Description of involvement in external collaborative activity Yes TC04 - Patients/families/caregivers are involved in practice governance Elective Documented process AND Yes Evidence of implementation Yes TC05 - Uses a certified EHR system Elective Certified Electronic Health Records System (EHR) name Yes TC06 - Practice wide care team meetings to share information Core Documented process AND Yes Evidence of implementation No TC07 - Involves care team in quality improvement activities Core Documented process AND Yes Evidence of implementation Yes TC08 - Has a behavioral care manager Elective Identified behavioral healthcare manager Yes TC09 - Process to inform patients about medical home Core Documented process AND Yes Evidence of implementation Yes Criterion for Knowledge Management (KM) Core vs. Elective Evidence Type Eligible KM01 - Documents an up-to-date problem list for each patient Core Report OR No KM06 - predominant conditions or health concerns No KM02 - Comprehensive health assessment process implemented for all patients Core Documented process AND Yes Evidence of implementation No KM03 - Conducts depression screenings for adults and adolescents Core Evidence of implementation AND No [Report or No Documented process] Yes
KM04 - Conducts behavioral health screenings and/or assessments for two or more behavioral health conditions Elective Evidence of implementation AND No Documented process Yes KM05 - Assesses oral health provides services and/or coordinates with partners as necessary Elective Documented process AND Yes Evidence of implementation No KM06 - Identifies the predominant health concerns of the patient population Elective List of top priority conditions and concerns Yes KM07 - Understands social determinants of health for patients, monitors them, and implements interventions Elective Report AND No Evidence of implementation No KM08 - Evaluates patient population needs to tailor patient materials Elective Report AND Yes Evidence of implementation Yes KM09 - Collects information on how patients identify in at least three areas Core Report No KM10 - Assesses the language of its population Core Report No KM11 - Identifies and addresses needs in order to target health disparities and address staff health and cultural literacy Elective Evidence of implementation OR Yes Q1 05 and QI 13 Yes B & C) Evidence of implementation Yes KM12 - Reminds identified vulnerable patients about services Core A, B, D) Report/list and outreach materials Yes Report/list and outreach materials OR Yes KM13 Yes KM13 - Demonstrates excellence in a recognition program assessed care guidelines Elective Report OR No HSRP or DRP recognition for at least 75% of eligible clinicians No KM14 - Reviews and reconciles medications for >80% of patients from care transitions Core Report No KM15 - Maintains an up-to-date list of medications for more than 80% of patients Core Report No KM16 - Assesses understanding and provides education on new prescriptions for more than 50% of patients caregivers Elective Report AND No Evidence of Implementation No KM17 - Assesses and addresses patient response to medications and barriers to adherence for more than 50% of patients Elective Report AND No Evidence of Implementation No KM18 - Reviews controlled substance database when prescribing them Elective Evidence of implementation Yes based
AC07 - Has a secure electronic system for patient to request appointments, prescription refills, referrals, and test results Elective Evidence of implementation Yes AC08 - Has a secure electronic system for two-way communication to provide timely clinical advice Elective Documented process AND Yes Report Yes AC09 - Uses information about the population served by the practice to assess equity of access Elective Evidence of implementation No AC10 - Helps patients/caregivers select or change a personal clinician Core Documented process Yes AC11 - Sets goals and monitors the percentage of patient visits with the selected clinician or team Core Report No AC12 - Provides continuity of medical record information for care and advice when the office is closed Elective Documented process Yes AC13 - Reviews and actively manages panel size Elective Documented process AND Yes Report No AC14 - Reviews and reconciles panels based on health plan or other outside patient assignments Elective Documented process AND Yes Evidence of implementation No Criterion for Care Management (CM) Core vs. Elective Evidence Type Eligible CM01 - Considers 3 out of 5 NCQA measures when identifying patients who may benefit from care management Core Protocol for identifying patients for care management OR Yes CM03 Yes CM02 - Monitors the percentage of the total patient population identified through its process and criteria Core Report No CM03 - Applies a comprehensive process for patient Elective Report Yes CM04 - Establishes a care plan for patients identified for care management Core Report OR No [Record Review Workbook and No Patient examples] No CM05 - Provides a written care plan to the patient/family/caregiver for patients identified for care management Core Report OR No [Record Review Workbook and No Patient examples] No CM06 - Documents patient preference and functional/lifestyle goals in individual care plans Elective Report OR No [Record Review Workbook and No Patient examples] No CM07 – Identify and discuss potential barriers to meeting goals in individual care plans Elective Report OR No [Record Review Workbook and No Patient examples] No
CM08 - Includes a self-management plan in individual care plans Elective Report OR No [Record Review Workbook and No Patient examples] No CM09 - Care plan is integrated and accessible across settings of care Elective Documented process AND Yes Evidence of implementation Yes Criterion for Care Coordination (CC) Core vs. Elective Evidence Type Eligible CC01 - The practice systematically manages lab and imaging according to NCQA guidelines Core Documented process AND Yes Evidence of implementation No CC02 - Follows up with the inpatient facility about newborn hearing and blood-spot screening Elective Documented process AND Yes Evidence of implementation No CC03- Uses clinical protocols to determine when imaging and lab are necessary Elective Evidence of implementation Yes CC04 - The practice systematically manages referrals according to NCQA guidelines Core Documented process Yes Evidence of implementation No CC05 - Uses clinical protocols to determine when a referral to a specialist is necessary Elective Evidence of implementation Yes CC06 - Identifies the specialists/specialty frequently used by the practice Elective Evidence of implementation No CC07 - Considers performance information on specialists when making referrals Elective Data source AND Yes Examples Yes CC08 - Works with frequently referred specialists to set expectations for information sharing and patient care Elective Documented process OR Yes Agreement Yes CC09 - with behavioral healthcare providers to set expectations for information sharing and patient care Elective Agreement OR Yes [Documented process and Yes Evidence of implementation] Yes CC10 - Integrates behavioral healthcare providers into the care delivery system of the practice site Elective Documented process AND Yes Evidence of implementation No CC11 - Monitors the timeliness and quality of the referral response Elective Documented process AND Yes Report No CC12 - Documents co-management arrangements in the patient's medical record Elective Evidence of implementation No CC13 - Engages with patients regarding cost implications of treatment options Elective Documented process AND Yes Evidence of implementation No
SBMH02 – Establishes criteria and conducts necessary assessments to identify level of care for all consented students. Core Documented process AND TBD Evidence of implementation TBD SBMH03 -- Instructs patients on how to access health services when the school is closed (e.g. during summer months) including: A) Practice location with SBMH coordination, B) Access to medical record Core Documented process AND TBD Evidence of implementation TBD SBMH04 – Identifies and documents the patient’s PCP and provides information on available PCP’s to patients without them Core Documented process AND TBD Evidence of implementation TBD SBMH05 - Communicates the importance of patients following up with their primary provider. Core Evidence of implementation TBD SBMH06 – Shares a summary-of-care record with primary care provider. Core Documented process AND TBD Evidence of implementation OR Report TBD SBMH07 – Establishes coordinated care plan for selected patients (e.g. non PCMH with outside PCP) Elective Documented process AND TBD Evidence of implementation TBD SBMH08 – Informs patient/family/caregiver of care coordination plan for selected students and role of the SBMH. Elective Documented process AND TBD Evidence of implementation TBD SBMH09 – Informs patient of their right to confidential care Core Documented process AND TBD Evidence of implementation TBD SBMH10 – Provides visual and auditory privacy Core Documented process TBD SBMH11 – Offers reproductive health services to adolescent patients Elective Documented process AND TBD Evidence of implementation TBD SBMH12 – Provides co-located or integrated services that may include oral health, community health, health education, nutrition, vision Elective Documented process AND TBD Evidence of implementation TBD SBMH13 – Care team includes, at minimum, a 0.5 FTE behavioral health care provider at center site Core Job description TBD SBMH14 – Provides same day appointments for routine and urgent behavioral health care visits Elective Documented process AND TBD Evidence of implementation TBD SBMH15 – Develops a preparedness response plan for school crises Elective Documented process TBD