Applicable to PCPs and specialists (specialist practice must have lead responsibility for caremanagement for at least a subset of patients for a period of time; e.g., oncology care manager has lead responsibility for patients when they are in active chemotherapy).. For patients with anongoing care relationship with a specialist, PCP and specialist must establish agreement regarding who will have lead responsibility for care management.

To receive credit for an individual care management capability, basic care managementdelivered in the context of office visits must be available to all patients. Advanced care management, delivered by trained care managers in the context of provider-delivered caremanagement services, is expected to be available only to those members who have the providerdelivered care management benefit.

To facilitate phased implementation of capabilities, providers may select a subset of their patientpopulation for initial focus for capabilities 4.2, 4.5, 4.6, 4.7, 4.8, and 4.9

4.1

Practice Unit leaders and staff have been trained/educated and have comprehensive knowledge of the Patient-Centered Medical Home and Patient Centered Medical Home- Neighbor models, the Chronic Care model, and practice transformation concepts

PCP Guidelines:

1. Training content should include comprehensive information about the Chronic Care Model
   1. Reference information provided at the Improving Chronic Illness Care website
2. Training/educational activity is documented in personnel or training records, and content material used for training is available for review.
3. Process is in place to ensure new staff receive training
4. Process is in place to ensure all staff are apprised of changes in the PCMH and PCMH-N Interpretive Guidelines, and of the capabilities that have been implemented by the practice

Specialist Guidelines:

1. Training content should include comprehensive information about the Chronic Care Model and population management, and its relevance to specialists
2. Reference information provided at the Improving Chronic Illness Care website
   1. Training/educational activity is documented in personnel or training records, and content material used for training is available for review
3. Process is in place to ensure new staff receive training
4. Process is in place to ensure all staff are kept apprised of changes in the PCMH and PCMH-N Interpretive Guidelines, and of the capabilities that have been implemented by the practice

4.2

Practice Unit has developed an integrated team of multi-disciplinary providers and a systematic approach is in place to deliver coordinated care management services that address patients' full range of health care needs for the patient population selected for initial focus

PCP and Specialist Guidelines:

1. The integrated team of multi-disciplinary providers must consist of at least 3 non-physician members, including an RN and at least 2 of the following (composition of team may vary depending on the needs of individual patients): certified diabetes educator, nutritionist (RD or Masters-trained nutritionist), respiratory therapist, PharmD or RPH, MSW, certified asthma health educator or other certified health educator specialist (Bachelors degree or higher in Health Education), licensed professional counselor, licensed mental health counselor, or an NP and/or PA with training/experience in health education who is actively engaged in care coordination/self-management training separate from their office visit E&M duties
   1. When they are unable to include Rns or PharmDs in the multi-disciplinary care management team, individual practices may use LPNs or PharmD students, in which case these ancillary providers with lesser training must be actively supervised by the physician and/or by a supervising RN or PharmD, with regard to the educational and care management interventions provided to each individual patient. This supervision must be provided either directly in the practice (e.g., by the primary care physician) or by staff employed by the Physician Organization.
2. Practice unit team members hold regular team meetings and/or other structured communications about patients whose conditions are being actively managed.
3. All members of the team do not have to be at the same location or at the practice site, but care delivered by the team must be coordinated and integrated with the practice.
   1. When care is delivered by travel teams or at sites other than the practice:

4.3

Systematic approach is in place to ensure that evidence-based care guidelines are established and in use at the point of care by all team members of the Practice Unit

PCP Guidelines:

1. Guidelines are available and used at the point of care by all clinical staff in the Practice Unit
   1. Guidelines are activated and used regularly to provide alerts about gaps in care on the Point of Care report or in the EMR
2. All members in the practice, including front office staff who work with clinicians and patients, are knowledgeable about the type and length of appointments to book and their responsibilities for preparing resources for visits, based on the guidelines
   1. Guidelines are actively used to monitor, track, and conduct outreach to patients to schedule care as needed
3. Guidelines are used by PO to evaluate performance of physicians, Practice Units, and PO.

Specialist Guidelines:

1. Evidence-based care guidelines may be those developed by specialist societies
2. Guidelines are available and used at the point of care by all clinical staff in the Practice Unit
   1. Guidelines are activated and used regularly to provide alerts about gaps in care on the Point of Care report or in the EMR
3. All members in the practice, including front office staff who work with clinicians and patients, are knowledgeable about the type and length of appointments to book and their responsibilities for preparing resources for visits, based on the guidelines
   1. Guidelines are actively used to monitor, track, and conduct outreach to patients to schedule care as needed
4. Guidelines are used by PO to evaluate performance of physicians, Practice Units, and PO.

4.4

PCMH/PCMH-N patient satisfaction/office efficiency measures are systematically administered

PCP Guidelines:

1. Patient satisfaction and office efficiency measures (e.g., patient waiting time to obtain appointment, office visit cycle time, percentage of no-show appointments) are monitored
   1. Measures must be derived from surveys conducted by the office or from information provided by health plans, the PO, or other sources

4.5

Development and incorporation into the medical record of written action plan and goal setting is systematically offered to the patient population selected for initial focus, with substantive patient-specific and patient-friendly documentation provided to the patient

PCP and Specialist Guidelines:

1. Physicians and other practice team members are actively involved in working with patients to use goal-setting techniques and develop action plans
   1. Goal-setting should focus on specific changes in behavior (e.g., walking around the block once a day) or concrete, tangible results (e.g., losing 2 pounds) rather than general clinical goals (such as lowering blood pressure or reducing LDL levels)
2. Patient-specific action plan and patient’s individual goals must be documented in medical record, enabling providers to monitor and follow-up with patient during subsequent visits
3. Reference information provided at the Improving Chronic Illness Care website

4.6

A systematic approach is in place for appointment tracking and generation of reminders for the patient population selected for initial focus

PCP and Specialist Guidelines:

1. Evidence-based guidelines are used systematically as a basis for:
   1. Conducting tracking and follow-up regarding missed appointments
   2. Providing patients with mail and/or telephone reminders of upcoming appointments

4.7

A systematic approach is in place to ensure that follow-up for needed services is provided for the patient population selected for initial focus

PCP and Specialist Guidelines:

1. Evidence-based guidelines are used systematically as a basis for:
   1. Following up with patients to ensure that needed services, whether at the PCMH/PCMH-N practice site or at another care site, are obtained by the patients

4.8

Planned visits are offered to the patient population selected for initial focus

PCP and Specialist Guidelines:

1. Planned visits consist of a documented, proactive, comprehensive approach to ensure that patients receive needed care in an efficient and effective manner.
   1. Planned visits include the well-orchestrated, team-based approach to managing the patient’s care during the visit, all performed on a routine basis, as well as the tracking and scheduling of regular visits, and the guideline-based preparation that occurs prior to the visit.
2. Reference information provided at the Improving Chronic Illness Care website
3. “Many healthcare providers believe themselves to already be doing ‘planned’ visits. They note that their patients with chronic conditions come back at defined intervals. Yet upon closer inspection, these visits may look a lot like acute care: the provider might lack necessary information about the patient’s care needs; provider and patient might have different expectations for the visit; and staff may not be fully utilized to help with the organization of the visit and delivery of care. These “check-back” visits, while scheduled in advance, are often not efficient nor productive for the provider and patient.
4. Key Components of a Planned Visit
   1. Assign Team Roles and Responsibilities
      • For example, the following questions might need to be addressed: who is going to call the patient to schedule the visit? Who will room the patient? If the patient has diabetes, who will remove her/his shoes and socks? Who will examine the feet? Who will prepare the patient encounter form for use during the visit? All tasks need to be delegated to specific team members so that nothing is left to chance.
   2. Call a Patient in For a Visit
      • Develop a script for the call, and decide which team member will make the call. Set the tone and expectations for the issues addressed in the visit.
      • If you choose to mail an invitation to patients, be sure to track respondents. Typically, less than 50% of patients respond to a letter. You will need to plan an alternative method of contacting non-responders.
   3. Deliver Clinical Care and Self-Management Support
      • In preparation for the visit, print an encounter form from your registry or pull the chart in advance so that you can review the patient’s care to date. Document what clinical care needs to be done during the visit.
   4. Until new roles are well integrated into the normal work flow, many practices have team huddles for 5-10 minutes…to review the schedule and identify chronic care patients coming in that day for an acute care visit. Decide how best to meet as a team to manage these patients. Determine the best intervals and timing for these meetings, and stick to them. The brief get-togethers help the team stay focused on practice redesign and create a spirit of ‘one for all’.”

4.9

Group visit option is available for the patient population selected for initial focus (as appropriate for the patient)

PCP and Specialist Guidelines:

1. Reference AAFP information on group visits
2. Group visits are a form of office visit. (They are not the same as care coordination/care management services, which are follow-up services delivered by non-physician clinicians antecedent to an office visit at which individual treatment and/or health behavior goals have been established.)
3. Group visits include not only group education and interaction but also all essential elements of an individual patient visit, including but not limited to the collection of vital signs, history taking, relevant physical examination and clinical decision-making.
   1. Group visits differ from other forms of group interventions, such as support groups,which are generally led by peers and do not include one-on-one consultations with physicians.
4. The clinician is directly involved and meets with each patient individually
   1. NP or PA may conduct both the clinical and educational/group activity components of the group visit
5. Members of the care management team may take vital signs and other measurements and assist with individual encounters
6. Dietitians or pharmacists may lead educational sessions. Topics such as medication management, stress management, exercise and nutrition, and community resources, may be suggested by the group facilitator or by patients, who raise concerns, share information and ask questions. In programs emphasizing self-management, physicians and patients work together to create behavior-change action plans, which detail achievable and behavior specific goals that participants aim to accomplish by the next session. Once plans are set, the group discusses ways to overcome potential obstacles, which raises patients' self efficacy and commitment to behavioral change. Patients' family members can also be included in these group sessions.”
7. Group visits generally last from two to 2.5 hours and include no more than 20 patients at a time.
8. Group visits may be conducted in collaboration with other Practice Units

4.10

Medication review and management is provided at every visit for all patients with conditions requiring management

PCP Guidelines:

1. At a minimum, medication review and management is provided at every visit for all patients with chronic conditions.
   1. Chronic conditions under 4.10 are defined as any condition requiring maintenance drug therapy.
   2. During every patient encounter, a list of all medications currently taken by the patient is reviewed and updated, and any concerns regarding medication interactions or side effects are addressed.

Specialist Guidelines:

1. At a minimum, medication review and management is provided at every visit for all patients with chronic conditions or when indicated given the patient’s health status
   1. Chronic conditions under 4.10 are defined as any condition requiring maintenance drug therapy.
   2. During every patient encounter, a list of all medications currently taken by the patient is reviewed and updated, and any concerns regarding medication interactions or side effects are addressed.

4.11

Development and incorporation into medical record of written action plans and goal-settingis systematically offered to all patients with chronic conditions or other complex health care needs prevalent in practice’s patient population

PCP and Specialist Guidelines:

1. Reference 4.5

4.12

A systematic approach is in place for appointment tracking and generation of reminders for all patients

PCP and Specialist Guidelines:

1. Reference 4.6

4.13

A systematic approach is in place to ensure follow-up for needed services for all patients

PCP and Specialist Guidelines:

1. Reference 4.7

4.14

Planned visits are offered to all patients with chronic conditions (or, for some specialists, allsub-acute conditions) prevalent in practice population

PCP and Specialist Guidelines:

1. Reference 4.8

4.15

Group visit option is available to all patients with chronic conditions (or, for some specialists,all sub-acute conditions) prevalent in practice population

PCP and Specialist Guidelines:

1. Reference 4.9

4.16

A systematic approach is in place for engaging patients in conversation about advance careplanning, executing an advance care plan with each patient who wishes to do so, and including a copy of a signed advance care plan in the patient’s medical record

PCP Guidelines:

1. PCP must have systematic process in place to communicate with specialists and identify whohas lead responsibility for discussing and assisting each patient with advance care planning
   1. Training and information about advance care planning is available from the Centersfor Disease Control and through a number of healthcare organizations
2. Provider with lead responsibility must ensure that all care partners are aware of and havecopies of advance care plan

Specialist Guidelines:

1. Specialist(s) must have systematic process in place to communicate with PCP and identify who has lead responsibility for discussing and assisting each patient with advance care planning
   1. Specialists are not expected to engage in advance care planning with patientsvisiting for routine, basic care
   2. Training and information about advance care planning is available from the Centersfor Disease Control and through a number of healthcare organizations
2. Provider with lead responsibility must ensure that all care partners are aware of and havecopies of advance care plan

4.17

A systematic approach is in place for developing a survivorship plan for patients oncetreatment is completed, including a copy of the survivorship plan in the patient’s medical record, and ensuring that the plan is shared with the patient and the patient’s providers

PCP and Specialist Guidelines:

1. PCP and specialist(s) must have systematic process in place to identify who has lead responsibility for developing each patient’s individualized patient survivorship care plan that includes guidelines for monitoring and maintaining the health of patients who havecompleted treatment
   1. Information about survivorship plans
2. Provider with lead responsibility must ensure that key care partners are aware of and have copies of the survivorship care plan

4.18

A systematic approach is in place for assessing patient palliative care needs and ensuring patients receive needed palliative care services

PCP and Specialist Guidelines:

1. PCP and specialist(s) have systematic process in place to identify who has lead responsibilityfor addressing each patient’s palliative care needs
   1. Provider with lead responsibility ensures that all care partners are aware thatpatient is receiving palliative care services
2. Reference for definition of palliative care, and an overview of the domains that should be addressed in the delivery of palliative care
3. Practice has established written protocols for determining when patients should beassessed for palliative care needs, based on accepted standards relevant to their patient population.
   ​Tools that can be used to support assessment of palliative care needs are available here: http://www.palliative.org/newpc/professionals/tools/esas.html
   http://www.hpsm.org/documents/End_of_Life_Summit_FICA_References.pdf
   http://www.cqaimh.org/pdf/tool_phq9.pdf
   http://www.cqaimh.org/pdf/tool_phq2.pdf
4. Options for delivery of palliative care include:
   1. Delivery within practice: At least one member of practice has received trainingthrough established palliative care training program, and has educated other practice staff. For domains that cannot be addressed directly by practice staff,practice has knowledge of community resources that will enable patient to receive palliative care across all domains (e.g., legal, ethical, spiritual).
   2. Referrals: Practice maintains information on availability of comprehensive palliativecare teams, and makes referrals as appropriate. Sources for referral can be found at mihospice.org

4.19

Systematic process is in place to identify patients who would benefit from care managementservices based on clinical conditions and ED, inpatient, and other service use

PCP and Specialist Guidelines:

1. PCP and specialists must have systematic process in place to identify patients who arecandidates for care management, and to document the results of the identification process
   1. PCPs should notify specialists when patient has care manager
   2. Specialists should notify PCPs when specialist has care manager
   3. When there is more than one care manager, the involved providers should coordinate to identify care manager with lead responsibility 

4.20

Systematic process is in place to inform patients about availability of care management services

PCP and Specialist Guidelines:

1. PCP and specialist(s) must have systematic process in place to inform patients aboutavailability of care management services, and to document the conversation and the patient’s response

4.21

Inter-disciplinary team meetings are held regularly to conduct patient case reviews, withdevelopment and review of comprehensive care plans for medically complex patients

PCP and Specialist Guidelines:

1. PCP and specialist(s) must have systematic process in place to conduct and documentregular patient case reviews, and develop and review comprehensive care plans for medically complex patients
   1. Common elements of a comprehensive care management plan include:
      1. Full problem list
      2. Expected outcome and prognosis
      3. Measureable treatment goals
      4. Symptom management
      5. Planned interventions
      6. Medication management
         • Medication allergies
      7. Community/social services ordered
      8. Plan for directing/coordinating the services of agencies and specialists which are notconnected to the practice
      9. Identify individual who is responsible for each intervention