All capabilities and guidelines are applicable to PCPs for all current patients (regardless of insurance coverage). “Current” patients for PCPs are defined as patients who the practice unit considers to be active in the practice (e.g., practices may define “current” as seen within the past 12 months or 24 months)

Capabilities 1.1-1.3 and 1.9 are applicable to specialists. For specialists, there are two ways to implement the patient-provider partnership capabilities: 1) specialist has patient-provider partnership discussion with “current” patients with whom the specialist has an ongoing treating
relationship, which is defined as “having primary responsibility or co-management responsibility with PCP for patients with an established chronic condition”; 2) specialist has patient-provider partnership discussion with all patients at the onset of treatment.

1.1

Practice unit has developed PCMH-related patient communication tools, has trained staff,and is prepared to implement patient-provider partnership with each current patient, which may consist of a signed agreement or other documented patient communication process to establish patient-provider partnership

PCP and Specialist Guidelines:

1. Patient communication process must include a conversation between the patient and a member of the clinical practice unit team. In extenuating circumstances, well-trained Medical Assistants who are highly engaged with patient care may be considered a member of the clinical practice unit team.
2. The patient-provider partnership must only be established one time per patient.
3. Documentation may consist of note in medical record, sticker placed on front of the chart,indicator in patient registry, patient log, or similar system that can be used to identify the percent of patients with whom the partnership has been discussed.
4. Documents and patient education tools are developed that explain PCMH concepts and outline patient and provider roles and responsibilities.
5. Practice unit team members and all appropriate staff are educated/trained on patient provider partnership concepts and patient communication processes
6. Process has been established for patients to receive PCMH information, and for practitioner to have conversation with patients about PCMH patient-provider partnership.
7. Mechanism and process has been developed to document establishment of patient provider partnership in medical record or patient registry.

1.2

Process of reaching out to current patients is underway, and practice unit is using a systematic approach to inform patients about PCMH

PCP Guidelines:

1. Outreach process must include patients who do not visit the practice regularly
2. Examples of outreach include discussion at the time of visit, mailings, emails, telephone outreach, or other electronic means
   1. Mass mailings do not meet the requirements for 1.3 through 1.8
   2. Outreach materials should explain the PCMH concept and patient-provider partnership
   3. For any reference to a practice having “BCBSM Designation status” please referenceBCBSM’s recommended language for communications to patients from PCMH Designated practices
3. For those patients who do not come into the practice regularly, outreach must consist of distribution of targeted material that the patient receives personally, either via mail, email, telephone, or patient portal.
   1. Postings on websites do not meet the intent of this capability

Specialist Guidelines:

1. Examples of outreach include discussion at the time of visit, mailings, emails,telephone outreach, or other electronic means. Mass mailings do not meet the requirements for 1.3 Outreach materials should explain the PCMH concept and patient-provider partnership, and the roles and responsibilities of the specialist provider, the PCP, and the patient

1.3

Patient-provider agreement or other documented patient communication process is implemented and documented for at least 10% of current patients

PCP Guidelines:

1. Establishment of patient-provider partnership must include conversation between patient and a member of the practice unit clinical team
   1. In extenuating circumstances, well-trained Medical Assistants who are highly engaged with patient care may be considered a member of the clinical practice unit team.
   2. Conversation should preferably take place in person, but may take place over phone in extenuating circumstances, for a limited number of patients
   3. Other team members may begin the conversation, or follow-up after physician conversation with more detailed discussion/information, but a clinical team member must participate in at least part of the patient-provider partnership conversation
2. Conversation may be documented in medical record, patient registry, or other type of list.
3. Practice must also have mechanism to track percent of patients that have established partnership, and be able to provide data during site visit showing denominator (total number of “current” patients in the practice) and numerator (total number of patients in the denominator with whom conversations have been held and partnerships established at any point in the past).

Specialist Guidelines:

1. Evidence must be provided that patient-provider partnership conversations are occurring with, at a minimum, those patients for whom the specialist has primary responsibility or comanagement responsibility with PCP
   1. It is not necessary to maintain a list for purposes of quantifying the percentage of patients engaged in patient-provider partnership conversations
2. Establishment of patient-provider partnership must include conversation between patient and a member of the practice unit clinical team
   1. In extenuating circumstances, well-trained Medical Assistants who are highly engaged with patient care may be considered a member of the clinical practice unit team.
   2. Conversation should preferably take place in person, but may take place over phone in extenuating circumstances, for a limited number of patients
   3. Other team members may begin the conversation, or follow-up after physician conversation with more detailed discussion/information, but a clinical team member must participate in at least part of the patient-provider partnership conversation
3. Conversation may be documented in medical record, patient registry, or other type of list

1.4

Patient-provider agreement or other documented patient communication process is implemented and documented for at least 30% of current patients

PCP Guidelines:

1. Reference 1.3

1.5

Patient-provider agreement or other documented patient communication process is implemented and documented for at least 50% of current patients

PCP Guidelines:

1. Reference 1.3

1.6

Patient-provider agreement or other documented patient communication process is implemented and documented for at least 60% of current patients

PCP Guidelines:

1. Reference 1.3

1.7

Patient-provider agreement or other documented patient communication process is implemented and documented for at least 80% of current patients

PCP Guidelines:

1. Reference 1.3

1.8

Patient-provider agreement or other documented patient communication process is implemented and documented for at least 90% of current patients

PCP Guidelines:

1. Reference 1.3

1.9

Providers ensure that patients are aware that as part of comprehensive, quality care and to support population management, health care information is shared among care partners as necessary.

PCP and Specialist Guidelines:

1. Providers ensure that patients are aware and clearly understand that in the course of providing care, providers will share patient information with other providers who are involved in the patient's care, as appropriate. The data sharing may be through provision of written medical information or through electronic sharing of information (for example, electronic transmission of information about admissions, discharges and transfers from/to hospital-based care settings).
2. Language regarding the sharing of health information with other providers can be added to the patient-provider partnership documentation, or it may be incorporated into the practice’s existing HIPAA documentation, such as a “notice of privacy practices”, in order to fulfill the requirement to inform patients.