Transcript Patient Centered Medical Home

NCQA Recognition for Patient-Centered Medical Home
2011 Standards
Standard 2
Identify and Manage Populations
© Qualidigm
Identify and Manage Populations
Elements
 PCMH 2A: Patient Information
 PCMH 2B: Clinical Data
 PCMH 2C: Comprehensive Health Assessment
 PCMH 2D: Use of Data for Population Management –
MUST PASS
2A Patient Information
Scoring and Documentation
Practice uses a searchable electronic system and
records data >50% of the time for the
following:
1. Date of birth*
2. Gender*
3. Race*
4. Ethnicity*
5. Preferred language*
6. Telephone number
7. Email address
8. Dates of previous clinical visits
9. Legal guardian/healthcare proxy
10. Primary caregiver
11. Advance directives (N/A for pediatrics)
12. Health insurance
 3 Points
 Scoring
 9-12 factors = 100%
 7-8 factors = 75%
 5-6 factors = 50%
 3-4 factors = 25%
 0-2 factors = 0%
 Documentation
 Report showing percentage of
*Core Meaningful Use Requirement
patients who received electronic
copy of health information, access
to requested health information,
and electronic clinical summaries
2B Clinical Data
Scoring and Documentation
Practice uses a searchable electronic system to
record the following data:
1. Up-to-date problem list of active diagnoses
for >80% of patients
2. Allergies, including medications and
reactions, for >80% of patients
3. Blood pressure with date of recording for
>50% of patients
4. Height for >50% of patients
5. Weight for >50% of patients
6. BMI for >50% of patients
7. For pediatric patients, length/height,
weight, head circumference (<2 years) and
BMI percentile (age 2 to 20 years); for
>50% of patients
8. Tobacco use status for patients 13 years and
older for >50% of patients
9. List of prescription medications with date of
update for >80% of patients

4 Points

Scoring
 9 factors = 100%
 7-8 factors = 75%
 5-6 factors = 50%
 3-4 factors = 25%
 0-2 factors = 0%

Documentation
 Report showing percentage of all
patients seen in the last 3 months for
each data field
All factors are Core Meaningful Use requirements
2C Comprehensive Health
Assessment
Practice conducts and documents a health
assessment:
1. Age and gender appropriate
immunizations/screenings
2. Family/social/cultural characteristics
3. Communication needs
4. Medical history of patient and family
5. Advance care planning (N/A for
pediatric practices)
6. Behaviors affecting health
7. Patient and family mental
health/substance abuse
8. Developmental screening using
standardized tool (N/A for adult only
practices)
9. Depression screening for teens/adults
using standardized tool
Scoring and
Documentation
 4 Points
 Scoring
 8-9 factors = 100%
 6-7 factors = 75%
 4-5 factors = 50%
 2-3 factor = 25%
 0-1 factor = 0%
 Documentation
 Report or a completed patient
assessment (de-identified)
2D Use of Data for
Population Management
Scoring and
Documentation
Practice uses patient data and
evidence-based guidelines to generate
lists and to remind patients about
needed services:
1. At least 3 different preventive
care services*
2. At least 3 different chronic care
services*
3. Patients not recently seen by the
practice
4. Specific medications



*Menu Meaningful Use Requirement
MUST PASS
5 Points
Scoring
 4 factors = 100%
 3 factors = 75%
 2 factors = 50%
 1 factor = 25%
 0 factors = 0%
 Documentation
 Lists or summary reports of patients
who need services

Reports must contain at least 3 different
immunizations/screenings and at least 3
different acute/chronic care services
 Materials demonstrating patient
notification