to be RN or SW. The practice has an established methodology for the timely assignment of levels of care management/care coordination service needed by high-risk patients based on risk level, clinical information including disease severity level and other patient-specific characteristics. The purpose of the assessment is to promptly identify which high-risk patients should be in the care manager’s/care coordinator’s active caseload at any point in time. No NCQA requirement. NCQA: N/A TCPI: allow partial deeming. Separately verify that practice’s methodology is consistent with the Affordability Standard requirement to consider clinical information including severity level and other patient-specific characteristics. J: “The level of care to the care plan will vary and is by a x
to the The care manager/care coordinator completes within a specified period of time (from the time that the high-risk patient is placed in the care manager’s/care coordinator’s active caseload) a patient assessment based on the patient’s specific symptoms, complaints or situation, including the patient’s preferences and lifestyle goals, self-management abilities and socioeconomic circumstances that are contributing to elevated near-term hospitalization and/or ED risk. For children and youth, the care coordinator shall complete a family assessment that includes: a family status and environment assessment (i.e., assessment of medical/behavioral/dental health status; social supports of family and friends; financial needs; family 2011 PCMH 3, Element C, (Must Pass) requires the care team to collaborate with the patient/family to develop an individual care plan, including treatment goals that are reviewed and updated at each relevant visit for at least 75% of high-risk patients. NCQA PCMH 4, Element B: The care team and patient family/caregiver collaborate (at relevant visits) to develop and update an individual care plan for at least 75% of high risk patients; Care plan incorporates the patient preferences and functional lifestyle goals, identifies treatment goals, assesses and addresses potential barriers to meeting goals, includes a self-management plan and is given in writing to the patient/family/caregiver NCQA: The 2011 and 2014 NCQA requirements are not prescriptive time frame for completing the patient assessment and care plan. Allow NCQA deeming regarding content of patient assessment. Separately verify that the practice has established and implemented a process within specified timeframes for assessing and adding new patients onto the High Risk Patient List, based on care manager capacity. J: a and family that family status and home x family.
assessment, the care manager/care coordinator completes a written care plan, that includes: a medical/social summary risk factors treatment patient-generated goals barriers to meeting goals an action plan for attaining patient’s goals plan for at 75% of the patients identified as high risk. The care plan must include relevant treatment goals. 2014 NCQA PCMH 4, Element B: Care plan incorporates the patient preferences and functional lifestyle goals, identifies treatment goals, assesses and addresses potential barriers to meeting goals, includes a self-management plan and is given in writing to the patient/family/caregiver. 2014 NCQA PCMH 4 requires that 75% of patients on high risk list have a care plan. specify the content of the care plan in sufficient detail and do not specify a time table for completing the care plan. Do not allow deeming. 2014 PCMH NCQA requirements do not specify a time table for completing care plans. Allow deeming regarding content of written patient care plan. Separately verify that the practice is meeting the timeline. TCPI: do not allow deeming, as TCPI’s requirements are not sufficiently specific. J: with the family, a care plan, a action plan, and, if an
note: we did not specify Could build into care For high-risk patients known to be hospitalized or in a SNF, the care management/care coordination resources shall contact the patient and/or the 2011 and 2014 NCQA PCMH 5, Element C, Factor 4 requires practices to proactively contact patient/families for appropriate follow-up care within NCQA: Allow partial deeming and separately verify that the practices are beginning TOC C: x
in their K). The care management/care coordination resources contact high-risk patient who has been discharged from hospital inpatient services after discharge to determine care management needs. 2011 and 2014 NCQA PCMH 5, Element C, Factor 4 requires practices to proactively contact patient/families for appropriate follow-up care within an appropriate period following a hospital admission or ED No timeframes are specified. NCQA: Allow partial deeming and separately verify that the practices are meeting the specific timeframe for completing the outreach contacts. TCPI: allow deeming note: did not on A x x x
could in their K). The care management/care coordination resources contact every known high-risk who has had an Emergency Department visit for a situation or condition that is related to or contributes to the patient’s high-risk status. 2011 and 2014 NCQA PCMH 5, Element C, Factor 4 requires practices to proactively contact patient/families for appropriate follow-up care within an appropriate period following a hospital admission or ED visit. No timeframes are specified. NCQA: Allow partial deeming and separately verify that the practices are meeting the specific timeframe for completing the outreach contacts. TCPI: allow deeming note: did not on A could x x x
in their K). The care management/care coordination resources complete a medication reconciliation after a high-risk patient has been discharged from inpatient services; to the extent possible the medication reconciliation is conducted in person. 2011 NCQA PCMH 3, Element D specifies percentages of care transitions for which medication reconciliations are to be done. 2014 NCQA PCMH 4, Element C (Critical Factor): practice reviews and reconciles medications for more than 50% of patients received from care transitions (factor 1); with patients/families for more than 80% of care transitions (Factor 2). Medication reviews must occur at least annually, at transitions of care and at relevant visits, as defined by the practices. NCQA: Allow partial deeming and separately verify that the practices are meeting the specific timeframe for completing the medication reconciliations. TCPI: allow deeming if the practice has selected medication management review as one of its case management strategies. note: did not on timing. A could x x x
in their K). The care management/care coordination resources arrange for, and coordinate all medical, developmental, behavioral health and social service referrals and tracks referrals and test results on a timely basis for high-risk patients. 2011 and 2014 NCQA PCMH 5, Element A requires practices to systematically track tests and coordinate care across specialty care, facility-based care and community organizations. 2011 and 2014 NCQA PCMH 5 Element B, (Must Pass) requires practices to track and follow-up on referrals. Practices are to track referrals that are “determined by the clinician to be important to a patient’s treatment, or as indicated by practice guidelines. This includes referrals to medical specialists, mental health and NCQA: deeming TCPI: deeming once milestone Phase 4.E is achieved. J: “[Care will] for, set up, and all x
substance abuse specialists and other services. health, and social and and test The care management/care coordinator resources provide health and lifestyle coaching for high-risk patients designed to enhance the patient’s/caregiver’s self/condition-management skills. 2011 NCQA PCMH 4, Element A (Must Pass) requires the practice to conduct activities to support patient/families in self-management, including providing educational resources and referrals to educational resources, self-management tools, providing healthy behaviors coaching, and developing and document plans and goals. NCQA: Allow deeming TCPI: Do not allow deeming, as the standard is too general. J: and related x
with to care for their and Practices provide training to care managers/care coordinators, as necessary, to achieve these requirements 2014 NCQA PCMH 2, Element 6 requires practices to train and assign members of the care team to support patients/families/caregivers in self-efficacy and behavioral change. NCQA: all deeming. Patient engagement will necessarily be a topic of these training activities because it is foundational to self-management, self, efficacy and behavioral change. TCPI: partial deeming. Separately verify that training topics include patient engagement. F: care staff will attend at least one x
notes: could patient in this The care management/care coordination resources have in-person or telephonic contact with each high-risk patient at intervals consistent with the patient’s level of risk. 2011 NCQA PCMH 3, Element C requires the practice to develop care for at least 75% of high-risk patients and to follow-up with patients/families who have not kept important appointments. 2014 NCQA PCMH 4, Element B requires care plans for 75% of high risk patients, but includes no contact requirements NCQA: The 2011 and 2014 NCQA standards do not include specific contact requirements. Do not allow deeming TCPI: No not deeming, as the requirement is too general. J: “The level of care to the care x require
The care management/care coordination resources participate in relevant care meetings to assure care is provided to high-risk patients. For pediatric practices, participants in practice-initiated team meetings may include primary care and specialist providers, school liaisons, behavioral health providers, developmental specialists, government support program representatives (e.g., SSI), and social service agency representatives. 2011 NCQA PCMH 1, Element G requires the practice to use a team to provide a range of patient care services. 2014 NCQA PCMH 2, Element D (Must Pass) requires that the practice uses a team to provide a range of patient services by holding a scheduled patient care team meeting or structured communication process focused on individual patient care (Factor 3, CRITICAL factor). NCQA Explanation states that all clinical staff are members of the team. NCQA: Allow deeming TCPI: do not allow deeming, as the requirement is too general. J: the health care team of health care this x
deliver and care and the of service The care management/care coordination resources participate in formal practice quality improvement initiatives to and improve effectiveness of care management service delivery 2011 NCQA PCMH 1, Element G, Factor 8 and 2014 NCQA PCMH 2, Element D, Factor 9 (Must Pass): The practice uses the team to provide a range of patient services by involving the care team in the practice’s performance evaluation and quality improvement activity. NCQA: deeming TCPI: Allow partial deeming when Phase 2.H is achieved. Separately verify that PDSA cycles and improve effectiveness of care notes: we do not have this x
access: (Must Pass): The practice has a written process and defined standards and regularly assesses its performance on : Providing same appointments for routine and urgent care (Critical Factor) TCPI: Do not allow deeming, as requirements are not sufficiently specific. Hannah notes: no for Most do this already. NCQA 3. The practice has an agreement with (or established) an urgent care clinic or other service provider which is open during evenings and weekends when the office is not open as an alternative to receiving Emergency Department care. No NCQA requirement. N/A TCPI: Do not allow deeming, as requirements are not sufficiently specific. See above for of having After Hours Policy. x require require
2014 NCQA PCMH 1, Element A, Factor 6 requires practices to act “on identified opportunities to improve access.” The Explanation for Factor 6 states: The practice may participate in or implement a improvement process, such as Plan-Do-Study-Act (PDSA), that represents a commitment to ongoing quality improvement and goes beyond goals and taking action. NCQA 2014: Allow deeming. TCPI: Allow partial deeming if Phase 2 H is met. Separately verify that PDSA cycles are designed to assess and improve the effectiveness of its programs to expand access. Allow deeming once Phase 4. A milestone is achieved. NCQA The practice must perform at least 2 of the following functions: The practice has created a secure web portal that enables patients to: send and receive secure messaging request appointments request referrals request prescription refills review lab and imaging results The practice clearly communicates to patients that the portal should not be used for urgent matters and that patients should call the practice under such circumstances. 2011 NCQA PCMH 1, Element C, Factors 5 and 6 requires practices to have electronic access, including requesting appointments or prescription refills (Factor 5) and referrals or test results (Factor 6). 2014 NCQA PCMH 1, Element C, Factor 6: Patients can request appointments, prescription refills, referrals and test results; this is also a core meaningful use requirement NCQA: Allow deeming. TCPI: N/A Hannah notes: did not require. NCQA x x x The practice has expanded office hours so that services are available at least two mornings or two evenings a week for a 2011 NCQA PCMH 1, Element BG, Factor 2 requires practices to provide access to routine and The 2011 and 2014 NCQA standards are not specific regarding expanded office hours. Hannah did not x x
practice early (e.g., a weekday afternoon or holiday). The practice has expanded office hours so that services are available at least four hours over the weekend. Services may be provided by practice clinicians or through an affiliation of clinicians, so long as the affiliated physicians are able to share medical information electronically on a near real- time basis through either a shared EMR system or by ready access to a patient’s practice physician who has access to patient’s medical records. 2011 and 2014 NCQA PCMH standards: Same as above. NCQA is less specific regarding to what extent hours must be expanded. The 2011 and 2014 NCQA standards are not specific regarding expanded office hours. NCQA: Do not allow deeming. TCPI: N/A Hannah did not said they either met this already or it was not feasible to require in our x x Requirement #5: The practice refers patients to referral service providers who provide care. Cost Management Requirement NCQA Requirement Deeming Recommendation PCMH-Kids Common Contract Language Must be implemented by the end of: