PCMH 2018 Capabilities Clarifications

Lesson 2 the Changes

 

Capability Clarification

 

Interpretive Guideline 2.20

 

• 2.20 - Registry contains advanced patient information that will allow the practice to identify and address disparities in care
• Registry contains relevant advanced patient demographics, as listed in the guidelines (a minimum of four out of seven).

• Primary/preferred language
• Measures of social support (e.g., caretaker for disability, family network)
• Disability status
• Health literacy limitations
• Type of payer (e.g., uninsured, Medicaid)
• Relevant behavioral health information (e.g., date of depression screening and result)
• Social determinants of health such as housing instability, transportation limitations, food insufficiency, risk of exposure to violence

 

2.20 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: n/a

PCMH Validation Notes for Site Visits

• Registry contains relevant advanced patient demographics, as listed in the guidelines

20. least four of the seven elements).

 

Interpretive Guideline 4.10

 

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

PCP Guidelines:

• At a minimum, medication review and management is provided by clinical decision-maker at every visit for all patients with chronic conditions.

• Chronic conditions under 4.10 are defined as any condition requiring maintenance drug therapy.
• 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.
• Adjustments are made during every encounter to ensure list is current and matches current clinical needs, and any medication discrepancies or contraindications are resolved by a clinician

 

 

4.10 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: n/a PCMH Validation Notes for Site Visits

• Walk through medication reconciliation for patient scheduled to appear in office

 

Interpretive Guideline 4.14

 

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

• Added language from 4.8 clarifying expectations of planned visits (see guidelines)

 

4.14 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: 4.8 PCMH Validation Notes for Site Visits

 

Interpretive Guideline 4.16

• A systematic approach is in place for tracking patients’ use of advance care plans, including engaging patients in conversation about advance care planning, 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, and where appropriate conducting periodic follow-up conversations with patients who have not yet executed an advance care plan

 

Interpretation clarification

• Advance Care Planning; conversation with patients, documentation, and demonstration offollow-up to patients who have been given advance care planning but have not returned paperwork.

 

4.16 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: n/a PCMH Validation Notes for Site Visits

• Advance Care Planning; conversation with patients, documentation, and demonstration of follow‐up to patients who have been given advance care planning but have not returned paperwork.
• Ask about who has conversation with patient. Does office have a template? If not the lead (specialist is) how are you informed of this? Specialist conversation? Sharing w/ PCP?

 

Interpretive Guideline 4.22

Provider initiating advance care plan in 4.16 ensures that all care partners are aware of and have copies of advance care plan

 

PCP and Specialist Guidelines:

• Provider with lead responsibility must ensure that all care partners are aware of and have copies of advance care plan
• When all practitioners are on a common EHR platform, there must be a systematic approach such as a flag or other notification mechanism to ensure all providers are aware that an advance care plan is in place

 

4.22 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: n/a PCMH Validation Notes for Site Visits

• Documentation that ACP was shared with care partners or systematic way to flag in EHR

 

Domain 5 – Extended Access

 

• Goal: All patients have timely access to health services that are patient-centered and culturally sensitive and are delivered in the most appropriate and least intensive setting based on the patient’s needs. Practice must be routinely referring non-emergent patients to after-hours care, whether located at the practice site or another urgent care center (i.e., specialist practices that always send patients to ED do not meet the criteria for having after-hours care capabilities in place).

 

5. Extended Access - This additional information is found in the box 2018 IG

• 10 total capabilities
• All capabilities applicable to:
• Adult and Peds patients
• Applicable to PCPs and specialists.

 

Interpretive Guideline 5.1

 

Patients have 24-hour access to a clinical decision-maker by phone, and clinical decision-maker has a feedback loop within 24 hours or next business day to the patient's PCMH

• PCP and Specialist Guidelines:
• Clinical decision-maker must be an M.D., D.O., D.C., licensed psychologist, P.A., or N.P. If not M.D. or D.O., clinical-decision maker must have ability to contact supervising

physician

 

5.1 This additional information is found in the box 2018 IG

Required for PCMH Designation: YES Predicate Logic: n/a PCMH Validation Notes for Site Visits Review process for 24‐hour coverage

 

Interpretive Guideline 5.3

PCP and Specialist Guidelines

Provider has made arrangements for patients to have access to non-ED after-hours provider for urgent care needs during at least 8 after-hours per week and, if different from the PCMH office, after-hours provider has a feedback loop within 24 hours or next business day to the patient's PCMH

• For urgent care centers, after-hours care is defined as additional evening (or early morning) and weekend availability (not 9 am- 5 pm) beyond the standard BCBSM urgent care participation agreement, which requires urgent care centers to be open at minimum 5-8 pm weekdays and 6 hours per day on Saturday and Sunday

 

5.3 This additional information is found in the box 2018 IG

137975829840. for PCMH Designation: NO Predicate Logic: n/a PCMH Validation Notes for Site Visits 8 after‐hours available (non‐ED ‐ Urgent Care) Review documentation related to accessing non‐ED centers when office closed

 

 

Interpretive Guideline 8.8

PCP and Specialist Guidelines

Electronic prescribing system is routinely used to prescribe controlled substances

• PCP and Specialist Guidelines:
• All practitioners routinely use an e-prescribing system to prescribe controlled substances
  • When possible, EHR or other automated system should be set to default to e-prescribing
  • At least 75% of controlled substance prescriptions should be electronic (Please review the Quarterly BC reports that are provided by Pharmacy Services while evaluating this capability).
• The field team may choose to review the rates prior to the site visit and evaluate the capability accordingly
• 1 year grace period will apply

 

This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: n/a PCMH Validation Notes for Site Visits

• Review BCBSM EPCS reports to support PU's active use

 

Interpretive Guideline 9.4

 

• Practice has process in place to inquire about a patient’s outside health encounters and incorporates information obtained from those sources about relevant preventiveservices in patient tracking system or medical record

 

****This is a change – this is not appropriate for most specialist offices, especially those that do not co-manage key chronic conditions****

 

9.4 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: n/a PCMH Validation Notes for Site Visits

• Demo an example of an outside health encounter ‐ update patient chart history w/dates of services

 

Interpretive Guideline 10.3

PO in conjunction with Practice Units has established collaborative relationships with appropriate community-based agencies and organizations

 

• PCP and Specialist Guidelines:
• Practice or PO in collaboration with practice is able to provide a list of organizations providing services relevant to their patient population in which collaborative, ongoing relationships are directly established
•  

****Practice MUST have active role****

 

10.3 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: n/a PCMH Validation Notes for Site Visits

• Example of relationship
• PO in conjunction w/ PU has conducted outreach to organizations

 

 

---

 

PCMH 2018 Capabilities Clarifications

Lesson 2 the Changes Capability Clarification

 

Welcome back to Patient Centered Medical Home and Neighborhood. Here are the major updates for 2018. Please see the Full Lesson below for all 2018 changes. We also have further attachments in the Documents section, so please review those as well. This section includes Capability updates.

 

2.20 Interpretive Guideline

 

• 2.20 - Registry contains advanced patient information that will allow the practice to identify and address disparities in care
• Registry contains relevant advanced patient demographics, as listed in the guidelines (a minimum of four out of seven).

• Primary/preferred language
• Measures of social support (e.g., caretaker for disability, family network)
• Disability status
• Health literacy limitations
• Type of payer (e.g., uninsured, Medicaid)
• Relevant behavioral health information (e.g., date of depression screening and result)
• Social determinants of health such as housing instability, transportation limitations, food insufficiency, risk of exposure to violence

 

2.20 This additional information is found in the box 2018 IG

• Registry contains relevant advanced patient demographics, as listed in the guidelines

20. least four of the seven elements).

 

 

4.10 Interpretive Guideline

 

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

PCP Guidelines:

• At a minimum, medication review and management is provided by clinical decision-maker at every visit for all patients with chronic conditions.

• Chronic conditions under 4.10 are defined as any condition requiring maintenance drug therapy.
• 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.
• Adjustments are made during every encounter to ensure list is current and matches current clinical needs, and any medication discrepancies or contraindications are resolved by a clinician

 

 

4.10 This additional information is found in the box 2018 IG

• Walk through medication reconciliation for patient scheduled to appear in office

 

4.14 Interpretive Guideline

 

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

• Added language from 4.8 clarifying expectations of planned visits (see guidelines)

 

4.14 This additional information is found in the box 2018 IG

Required for PCMH Designation: NO Predicate Logic: 4.8 PCMH Validation Notes for Site Visits

 

 

4.16 Interpretive Guideline

• A systematic approach is in place for tracking patients’ use of advance care plans, including engaging patients in conversation about advance care planning, 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, and where appropriate conducting periodic follow-up conversations with patients who have not yet executed an advance care plan

 

Interpretation clarification

• Advance Care Planning; conversation with patients, documentation, and demonstration offollow-up to patients who have been given advance care planning but have not returned paperwork.

 

4.16 This additional information is found in the box 2018 IG

• Advance Care Planning; conversation with patients, documentation, and demonstration of follow‐up to patients who have been given advance care planning but have not returned paperwork.
• Ask about who has conversation with patient. Does office have a template? If not the lead (specialist is) how are you informed of this? Specialist conversation? Sharing w/ PCP?

 

4.22 Interpretive Guideline

Provider initiating advance care plan in 4.16 ensures that all care partners are aware of and have copies of advance care plan

 

PCP and Specialist Guidelines:

• Provider with lead responsibility must ensure that all care partners are aware of and have copies of advance care plan
• When all practitioners are on a common EHR platform, there must be a systematic approach such as a flag or other notification mechanism to ensure all providers are aware that an advance care plan is in place

 

4.22 This additional information is found in the box 2018 IG

• Documentation that ACP was shared with care partners or systematic way to flag in EHR

 

Domain 5 – Extended Access

• Goal: All patients have timely access to health services that are patient-centered and culturally sensitive and are delivered in the most appropriate and least intensive setting based on the patient’s needs. Practice must be routinely referring non-emergent patients to after-hours care, whether located at the practice site or another urgent care center (i.e., specialist practices that always send patients to ED do not meet the criteria for having after-hours care capabilities in place).

 

5. Extended Access - This additional information is found in the box 2018 IG

• 10 total capabilities
• All capabilities applicable to:
• Adult and Peds patients
• Applicable to PCPs and specialists.

 

5.1 Interpretive Guideline

Patients have 24-hour access to a clinical decision-maker by phone, and clinical decision-maker has a feedback loop within 24 hours or next business day to the patient's PCMH

• PCP and Specialist Guidelines:
• Clinical decision-maker must be an M.D., D.O., D.C., licensed psychologist, P.A., or N.P. If not M.D. or D.O., clinical-decision maker must have ability to contact supervising

physician

 

5.1 This additional information is found in the box 2018 IG

 

5.3 Interpretive Guideline

PCP and Specialist Guidelines

Provider has made arrangements for patients to have access to non-ED after-hours provider for urgent care needs during at least 8 after-hours per week and, if different from the PCMH office, after-hours provider has a feedback loop within 24 hours or next business day to the patient's PCMH

• For urgent care centers, after-hours care is defined as additional evening (or early morning) and weekend availability (not 9 am- 5 pm) beyond the standard BCBSM urgent care participation agreement, which requires urgent care centers to be open at minimum 5-8 pm weekdays and 6 hours per day on Saturday and Sunday

 

5.3 This additional information is found in the box 2018 IG

 

8.8 Interpretive Guideline

PCP and Specialist Guidelines

Electronic prescribing system is routinely used to prescribe controlled substances

• PCP and Specialist Guidelines:
• All practitioners routinely use an e-prescribing system to prescribe controlled substances
  • When possible, EHR or other automated system should be set to default to e-prescribing
  • At least 75% of controlled substance prescriptions should be electronic (Please review the Quarterly BC reports that are provided by Pharmacy Services while evaluating this capability).
• The field team may choose to review the rates prior to the site visit and evaluate the capability accordingly
• 1 year grace period will apply

 

This additional information is found in the box 2018 IG

• Review BCBSM EPCS reports to support PU's active use

 

9.4 Interpretive Guideline

• Practice has process in place to inquire about a patient’s outside health encounters and incorporates information obtained from those sources about relevant preventiveservices in patient tracking system or medical record

 

****This is a change – this is not appropriate for most specialist offices, especially those that do not co-manage key chronic conditions****

 

9.4 This additional information is found in the box 2018 IG

• Demo an example of an outside health encounter ‐ update patient chart history w/dates of services

 

10.3 Interpretive Guideline

PO in conjunction with Practice Units has established collaborative relationships with appropriate community-based agencies and organizations

 

• PCP and Specialist Guidelines:
• Practice or PO in collaboration with practice is able to provide a list of organizations providing services relevant to their patient population in which collaborative, ongoing relationships are directly established
•  

****Practice MUST have active role****

 

10.3 This additional information is found in the box 2018 IG

• Type of payer (e.g., uninsured, Medicaid)
• Relevant behavioral health information (e.g., date of depression screening and result)

 

 

 

We hope you enjoyed these 2018 updates and please ensure any changes or protocol are taking place in your practice.