Patient Centered Medical Home

Standard 4Provide Self-Care Support and Community ResourcesNCQA Recognition for Patient-Centered Medical Home2011 Standards

Qualidigm

Provide Self-Care Support and Community ResourcesElementsPCMH 4A:Support Self-Care Process MUST PASS

PCMH 4B:Provide Referrals to Community Resources

4A Support Self-Care ProcessScoring and DocumentationPractice conducts activities to support patients in self-management:Provides education resources or refers at least 50% of patients to educational resourcesUses EHR to identify education resources and provide them to at least 10% of patients*Collaborates with at least 50% of patients to develop and document self-management plans and goals CRITICAL FACTORDocuments self-management abilities for at least 50% of patientsProvides self-management result recording tools to at least 50% of patientsCounsels at least 50% of patients in adopting healthy lifestyles

*Menu Meaningful Use Requirement

MUST PASS6 PointsScoring5-6 factors (including factor 3) = 100%4 factors (including factor 3) = 75%3 factors (including factor 3) = 50%1-2 factors = 25%0 factors = 0%DocumentationReport from electronic system or submission of Record Review Workbook

4B Provide Referrals to Community ResourcesScoring and DocumentationThe practice supports patients who need access to community resources:Maintains current resource list covering five (5) community service areas (e.g. smoking cessation, weight loss, parenting, dental, transportation, fall prevention, meal support)Tracks referrals provided to patientsArranges for, or provides treatment for, mental health/substance abuse disordersOffers opportunities for health education and peer support

3 PointsScoring4 factors = 100%3 factors = 75%2 factors = 50%1 factor = 25%0 factors = 0%DocumentationList of community services or agencies referral log or report covering at least one monthProcesses to provide/arrange for mental health/substance abuse treatment and health education supportStandard 5Track and Coordinate CareNCQA Recognition for Patient-Centered Medical Home2011 Standards

Qualidigm

Track and Coordinate CareElementsPCMH 5A:Test Tracking and Follow UpPCMH 5B:Referral Tracking and Follow Up MUST PASSPCMH 5C:Coordinate with Facilities and Care Transitions

5A Test Tracking and Follow UpScoring and DocumentationThe practice has documented the process for and demonstrates:Tracking lab tests and flagging and following up on overdue results CRITICAL FACTORTracking imaging tests and flagging and following up on overdue results CRITICAL FACTORFlagging abnormal lab resultsFlagging abnormal imaging resultsNotifying patients of normal and abnormal lab/imaging resultsFollowing up on newborn screening (N/A for adults)Electronically ordering and retrieving lab tests and resultsElectronically ordering and retrieving imaging tests and resultsElectronically incorporating at least 40% of lab results in records*Electronically incorporating imaging test results into records

*Menu Meaningful Use Requirement

6 PointsScoring8-10 factors (including factors 1 and 2) = 100%6-7 factors (including factors 1 and 2) = 75%4-5 factors (including factors 1 and 2 = 50%Fewer than 3 factors = 0%DocumentationProcess or procedure for staff and an example of how factors 1-6 are metElectronic system examples for factors 7-10

5B Referral Tracking and Follow UpScoring and DocumentationThe practice coordinates referrals:Provides the specialist with reason and key information for the referralTracks important referral status and timingFollows up to obtain specialist reportsDocuments agreements with specialists in the record if co-management is neededAsks patients about self-referrals and requests specialist reportsDemonstrates electronic exchange of key clinical information*Provides electronic summary of care for >50% of referrals**

*Core Meaningful Use Requirement**Menu Meaningful Use Requirement

MUST PASS6 PointsScoring5-7 factors = 100%4 factors = 75%3 factors = 50%1-2 factors = 25%0 factors = 0%DocumentationReports or logs demonstrating tracking system data collectionDocumented processes with 3 examplesReports from electronic system showing frequency of information exchange and summary of care records5C Coordinate with Facilities and Manage Care TransitionsScoring and DocumentationThe practice systematically demonstrates:Process to identify patients with hospital admissions or ED visitsProcess to share clinical information with hospital/EDProcess to obtain patient discharge summariesProcess to contact patients for follow-up care after dischargeProcess to exchange patient information with hospitalIT collaboration with patient to develop written care plan for transitions from pediatric to adult care (N/A for adults)Electronic exchange of key clinical information with facilities*Provision of electronic summary of care for >50% of transitions of care**

*Core Meaningful Use Requirement**Menu Meaningful Use Requirement

6 PointsScoring5-8 factors = 100%4 factors = 75%2-3 factors = 50%1 factor = 25%0 factors = 0%DocumentationDocumented process and examples for patient identification, providing clinical information, systematic follow up, obtaining discharge summaries, and two-way communicationCopy of a written transition care planReports illustrating electronic information exchangeElectronic report summarizing >50% care transitions