2020 Script
Thank you for watching the PCMH updates for 2020. Please see the attached PCMH 2020 full PDF in the Documents section below for all specific changes. We will now cover all major changes within these 2020 update videos that pertain to changes necessary within your practice.
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
PCP and Specialist Guidelines:
1.11
Practice has a regularly scheduled in-person new patient orientation that is distinct from a regularly scheduled visit, to set expectations about being a patient within that practice, and provide education about the value of a patient-centered medical home model.
PCP and Specialist Guidelines:
Orientation can be in a group setting and led by a mid-level provider, care team member (such as MSW, NP, PA, pharmacist, etc.), or nurse
This should ideally be presented as a group “interview” between the practice and prospective new patients, to ensure a good fit
a.c. Intended to be scheduled in advance as a group visit
2.5
Registry contains information on the individual practitioner for every patient currently in the registry who is an established patient in the practice unit
Registry may be paper or electronic
The individual practitioner responsible for the care of each patient is identified in the
2.20
Registry contains advanced patient information that will allow the practice to identify and address disparities in care
identify vulnerable patient populations, including race and ethnicity, and including data elements such as:
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)
7. social determinants of health such as housing instability, transportation limitations, food insufficiency, risk of exposure to violence
2.24
Registry is being used to manage patients identified as at-risk for future chronic conditions (e.g., pre-diabetes as evidenced by rising BMIs or, rising hemoglobin A1c;c, and assessment of relevant patient history, including medical, social, and hereditary factors) etc.) [Applicable to PCPs only]
PCP and Specialist Guidelines:
Registry may be paper or electronic
Reference 2.1(a)-(g)
An example of a diabetes prevention program is available here from the CDC
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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steps/treatment plan
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2.25
Registry is being used to identify patients with concerns related to social determinants of health, such as transportation limitations, housing instability, interpersonal violence, or food insecurity
PCP and Specialist Guidelines:
a. Registry may be paper or electronic
BCBSM PCMH and PCMH-N Interpretive Guidelines 20198-202019
b. Reference 2.1(a)-(g)
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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steps/treatment plan
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2.26
Social determinants of health data collected as part of 2.25 is shared routinely and electrootnically with the Michigan Institute for Care Management and Transformation
PCP and Specialist Guidelines:
Data sharing must be consistent with the guidelines set forth by the Michigan Institute for Care Management and Transformation (MICMT)
Visit the MICMT website for more information about data sharing guidelines
2.27
Registry is being used to identify patients in need of advance care planning, to ensure conversations are tracked appropriately
PCP and Specialist Guidelines:
c. Registry may be paper or electronic d. Reference 2.1(a)-(g)
Required for PCMH Designation: NO |
Predicate Logic: 2.25 |
PCMH Validation Notes for Site Visits |
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• MICMT is able to verify that they receive actionable, properly formatted data from the practice; practice demonstrates the can send data to MICMT. |
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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have no completed advance care planning documentation gaps in care? |
** REMEMBER TO FIND FULL 2020 UPDATES WITHIN THE BCBS FILE IN THE DOCUMENTS SECTION BELOW
3.0 Performance Reporting
3.19
Performance reports are generated for the population of patients with: advance care planning needs.
PCP and Specialist Guidelines:
a. Reference 3.1
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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• The practice must demo how they are using these performance reports to improve population management. • Steps: the patient population? o Percent of ACP completed and documented in HER o Percent of ACP not completed 3) What actions are taken? |
3.20
Performance reports are generated for the population of patients who are: at-risk for future
chronic conditions (e.g., pre-diabetes as evidenced by rising BMIs, rising hemoglobin A1c, etc.)
PCP and Specialist Guidelines:
a. Reference 3.1
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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• The practice must demo how they are using these performance reports to improve population management. o What condition has been chosen? • Steps: 1) Are the relevant measures included in the performance reports? What is the patient population? 2) What sort of review is being done with these reports? |
3) What actions are taken?
3.21
Performance reports are generated for the population of patients with: concerns related to
social determinants of health, such as transportation limitations, housing instability, interpersonal violence, or food insecurity.
PCP and Specialist Guidelines:
a.
Reference 3.1
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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• The practice must demo how they are using these performance reports to improve population management. • Steps: the patient population? |
4.0 Individual Care Management
4.1 - Required
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
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:
Note: The care team must include a clinical decision-maker working under the guidance of the physician.
4.3 - Required
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
Guidelines are available and used at the point of care by all clinical staff in the Practice Unit
i. Guidelines are activated and used regularly to provide alerts about gaps in care on the Point of Care report or in the EHR
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
i. Guidelines are actively used to monitor, track, and conduct outreach to patients to schedule care as needed
Guidelines are used by PO to evaluate performance of physicians, Practice Units, and PO.
Specialist Guidelines:
Evidence-based care guidelines may be those developed by specialist societies
Guidelines are available and used at the point of care by all clinical staff in the Practice Unit
i. Guidelines are activated and used regularly to provide alerts about gaps in care on the Point of Care report or in the EHR
c. 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
i. Guidelines are actively used to monitor, track, and conduct outreach to patients to schedule care as needed
d. Guidelines are used by PO to evaluate performance of physicians, Practice Units, and PO.
Required for PCMH Designation: YESNO |
Predicate Logic: n/a |
4.6- Required
A systematic approach is in place for appointment tracking and generation of reminders for
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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the patient population selected for initial focus
RETIRED
PCP and Specialist Guidelines:
a. Evidence-based guidelines are used systematically as a basis for:
Conducting tracking and follow-up regarding missed appointments
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:
a. Evidence-based guidelines are used systematically as a basis for:
Required for PCMH Designation: YES |
Predicate Logic: n/a |
RETIREDPCMH Validation Notes for Site Visits • Appointment reminder (upcoming appts) & tracking (no shows) for 1 chronic condition • Discuss appointment tracking process - follow up for no shows, demo recent example |
44
4.10 - Required
Medication review and management is provided at every visit for all patients with conditions requiring management
PCP Guidelines:
a. At a minimum, medication review and management are 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
Specialist Guidelines:
a. At a minimum, medication review and management are provided at every visit for all patients with chronic conditions or when indicated given the patient’s health status
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.
4.12 - Required
A systematic approach is in place for appointment tracking and generation of reminders for all patients
PCP and Specialist Guidelines:
a. Evidence-based guidelines are used systematically as a basis for:
Conducting tracking and follow-up regarding missed appointments
Providing patients with mail and/or telephone reminders of upcoming
appointments
4.13 - Required
A systematic approach is in place to ensure follow-up for needed services for all patients
PCP and Specialist Guidelines:
a. Evidence-based guidelines are used systematically as a basis for:
iii. 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
4.29
Physician organizations work with practices that employ Advanced Practice Providers, as outlined in the PGIP APP Acceleration Policy, and ensure consistency with attestation process and oversight responsibilities as described in section (g) in that document.
5.0 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
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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** REMEMBER TO FIND FULL 2020 UPDATES WITHIN THE BCBS FILE IN THE DOCUMENTS SECTION BELOW
5.1 - Required
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:
a. 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 M.D. or D.O. on an immediate basis if needed
i. Clinical decision-maker may be, but is not required to be, the patient’s primary care provider
b. Clinical decision-maker has the ability to direct the patient regarding self-care or to an appropriate level of care.
i. When reason for patient contact is not relevant to provider’s domain of care, provider will ensure that patient is able to contact PCP or another relevant provider
c. Clinical decision-maker communicates all clinically relevant information via phone conversation directly to patient’s primary physician, by email, by automated notification in an EHR system, or by faxing directly to primary physician regarding the interaction within 24 hours (or next business day) of the interaction
d. For after-hour calls, clinical decision-maker responds to patient inquiry in a timely manner (generally 15-30 minutes, and no later than 60 minutes after initial patient inquiry)
For urgent calls, clinical decision-maker responds to patient inquiry in a timely manner (generally 15-30 minutes, and no later than 60 minutes after initial patient inquiry)
For non-urgent calls during office hours, patients may be given response by phone before end of business day, or offered appointments in a timeframe appropriate to their health care needs
5.3
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 in a location different from the PCMH office, and, if different from the PCMH office, and after-hours provider has a feedback loop within 24 hours or next business day to the patient's PCMH
PCP Guidelines:
After-hours is defined as office visit availability during weekday evening (e.g., 5-8 pm) and/or early morning hours (e.g., 7-9 am) and/or weekend hours (e.g., Saturday 9-12), sufficient to reduce patients’ use of ED for non-ED care
After-hours provider is may be at Practice Unit site or may be in a physically separate location (e.g., an urgent care location or a separate physician office) as long as it is within 30 minutes travel time of the PCMH
i. Services provided by the after-hours provider must be billable as an office visit or an urgent care visit, not as an ER visit
c. Since If after-hours provider is different from Practice Unit (e.g., they are an urgent care center or a physician who shares on-call responsibilities), there must be an established arrangement for after-hours coverage, and the after-hours provider must be able to provide feedback regarding care encounter to the patient's Practice Unit within 24 hours or on the next business day
d. Practice Units may team with other practice units/physicians to provide after-hours urgent care
e.d. Patient referral to specialists, high tech imaging, and inpatient admissions recommended by urgent care providers should be made by or coordinated with PCP
f.e. Provider places high priority on avoiding unnecessary ED visits, and is routinely and systematically directing patients to after-hours care whenever appropriate
Specialist Guidelines:
g.f. After-hours provider is may be at Practice Unit site or may be in a physically separate location (e.g., an urgent care location or a separate physician office) as long as it is within 30 minutes travel time of the PCMH
i. Services provided by the after-hours provider must be billable as an office visit or an urgent care visit, not as an ER visit
h.g. Feedback from urgent care center is only required when the care provided to the patient is relevant to the condition being managed by the specialist
l. Practice Units may team with other practice units/physicians to provide after-hours urgent care
m.k. Patient referral to specialists, high tech imaging, and inpatient admissions recommended by urgent care providers should be made by or coordinated with PCP Provider who places high priority on avoiding unnecessary ED visits, and is routinely and systematically directing patients to after-hours care whenever appropriate
i
5.11
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, located within the provider’s office
5.12
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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• 8 after-hours available (non-ED Urgent Care in the provider’s office) |
Provider has made arrangements for patients to have access to non-ED after-hours provider for urgent care needs during at least 12 after-hours per week, located within the provider’s office
6.0 Test Results Tracking & Follow-up
6.2 - Required
Systematic approach and identified timeframes are in place for ensuring patients receive needed tests and practice obtains results
PCP and Specialist Guidelines:
Follow-up occurs with patients to ensure necessary tests are performed
Communication processes are in place with testing entities as necessary, to ensure results
are received
Results are reviewed, signed, and dated by the physician and noted in the patient’s medical
record
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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• 12 after-hours available (non-ED Urgent Care in the provider’s office) |
6.5 - Required
Systematic approach is used to inform patients about all abnormal test results
PCP and Specialist Guidelines:
Systematic approach is in place to flag as high priority results where follow-up is essential and the risk of not following up is high, i.e., tissue biopsies, diagnostic mammograms, INR tests
For high priority results, patient is contacted by phone (repeated attempts at different times of day, on different days if necessary; if necessary and acceptable to patient, email or patient portal may be used to request the patient call office; as a last resort, results may be sent by certified registered mail)
• Demo the process of identifying follow-up for necessary test.
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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Chart/Registry/EHR. If done through patient portal, practice will walk through the process of how info is transmitted from paper to portal. |
8.0 Electronic Prescribing and Management of Controlled Substance Prescriptions
Goal: All providers use electronic prescribing and actively manage controlled substance prescriptions
5 total capabilities; 2 retired
All capabilities applicable to: Adult and Peds patients
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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• Clinical staff demos using their registry or EHR. How are tests ordered through the system and how do results automatically feed back into the system? |
c. “Actively in use” is defined as greater than 75% of non-controlled prescriptions prescribed by the practice
8.8
Electronic prescribing system is routinely used to prescribe controlled substances
PCP and Specialist Guidelines:
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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8.9 - Retire
Michigan Automated Prescription System (renamed “PMP AWARxE”) reports are run prior to
prescribing controlled substances
a. All practitioners run PMP AWARxE reports prior to prescribing controlled substances, and follow-up with patient if any concerns are identified
8.11
Controlled Substance Agreements are shared with all patient’s care providers
All practitioners ensure that copies of Controlled Substance Agreements are given to all of RETIRED
the patient’s care providers
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 a controlled substance agreement is in place
9.0 Preventive Services
Goal: Actively screen, educate, and counsel patients on preventive care and health behaviors
119 total capabilities; 2 required
All capabilities applicable to: Adult and Peds patients
9.1 - Required
Primary prevention program is in place that focuses on identifying and educating patients about personal health behaviors to reduce their risk of disease and injury.
PCP and Specialist Guidelines:
Patient questionnaire or other mechanism is used to elicit information about personal health behaviors that may be contributing to disease risk
During well-visit exam and initial intake for new patients
During other visits when behavior may be relevant to acute concern (e.g., tobacco
use when patient presents with cough)
Patient assessment addresses personal health behaviors and disease risk factors, based on
age, gender, health issues
i. Behaviors and risks assessed should include a majority of the following (or other
primary prevention procedures) as appropriate to the patient population: Alcohol and Drug Use, Awareness of Lead Exposure, Breast Self-Examination, Low Fat Diet and Exercise, Use of Sunscreen, Safe Sex, Testicular Self-Examination, Tobacco Avoidance, and Flu Vaccine
9.2 Required
A systematic approach is in place to providing primary preventive services
PCP and Specialist Guidelines:
Preventive care guidelines are integrated into clinical practice (e.g., Michigan Quality Improvement Consortium - www.mqic.org). Examples of appropriate Guidelines include:
Adult Preventive Services Guideline 18-49 Yrs.
Adult Preventive Services Guideline 50-65 Yrs.
Childhood Overweight Prevention Guideline
Prevention of Unintended Pregnancy in Adults
Preventive Service for Children & Adolescents Ages Birth – 24 Months
Preventive Service for Children and Adolescents Ages 2-18 Yrs.
Tobacco Control Guideline
Systematic appointment tracking system (implemented as part of Individual Care
Management Initiative) is in place. Applies to full range of primary preventive services (for example, an ob-gyn ensuring patients receive mammograms and pap tests, but not flu shots, would not meet the intent of this capability).
9.5
Practice has a systematic approach in place to ensure the provision/documentation of tobacco use assessment tools and advice regarding smoking cessation
PCP and Specialist Guidelines:
a. Examples may include yearly assessment sheet, tobacco use intervention programs a.b. Approach should include education related to alternative forms of tobacco, such as e-
cigarettes (vaping) and hookah pipes
9.7
Secondary prevention program is in place to identify and treat asymptomatic persons who have already developed risk factors or pre-clinical disease, but in whom the disease itself has not become clinically apparent; or tertiary prevention to prevent worsening of clinically- established condition
PCP Guidelines and Specialist Guidelines:
a. System with guideline-based reminders for age-appropriate risk assessment and screening
tests, including for depression, is in place.
Practice Unit may choose to implement tools such as checklists attached to the patient chart, tagged notes, computer generated encounter forms and prompting stickers.
Systematic process is in place for following up on any positive screening results (e.g., process is in place for managing positive depression screenings]
Mechanisms are established to identify asymptomatic at-risk patients and provide additional screenings
Practice systematically uses point of care alerts based on identified risk
Examples include accelerated regimen for colon and breast cancer screening in high risk patients
Specialist Guidelines:
May not be applicable to some speciality types; only secondary preventive guidelines and testing recommendations that are applicable to the specialty type need to be addressed
clinical personnel on standards and guidelines such as AHRQ newsletter updates, the immunization schedule & standards issued by the Advisory Committee on Immunization Practices, Alliance of Immunization in Michigan, or Centers for Disease Control and Prevention.
▪For example, information may be provided to practice units educating them on appropriate billing and ICD-10 codes in order to ensure accurate reporting for preventive medicine services (including use of the correct ICD- 10 code for a physical)
9.10
Systematic approach is in place to screen for adult behavioral health disorders (e.g., substance abuse, depression, anxiety) for all patients
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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prior to the visit, what occurs during and post visit. |
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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9.11
Systematic approach is in place to screen for pediatric behavioral health disorders (e.g., autism, eating disorders) for all patients
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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10.0 Linkage to Community Services
10.2 - Required
PO maintains a community resource database based on input from Practice Units that serves as a central repository of information for all Practice Units.
PCP and Specialist Guidelines:
The database may include resources such as the United Way’s 2-1-1 hotline, and links to online resources such as www.auntbertha.com.
At least one staff person in the PO is responsible for conducting an semiannual update of the database and verifying local resource listings (PO may coordinate with Practice Unit staff to ensure resource reliability)
i. During the update process, consideration may be given to including new, innovative community resources such as Southeast Michigan Beacon Community’s Text4Health program
ii. It is acceptable for staff to not verify aggregate listings (such as 2-1-1) if they are able to document how often the listings are updated by the resource administrator
c. Resource databases are shared with other POs, particularly in overlapping geographic regions
d. Portion of database includes self-management training programs available in the community
10.4 - Required
All members of practice unit care team involved in establishing care treatment plans have received training on community resources and on how to identify and refer patients appropriately
PCP and Specialist Guidelines:
Training may occur in collaboration with community agencies that serve as subject-matter experts on local resources
Training occurs at time of hire for new staff, and is repeated at least annually for all staff
Practice unit care team is trained to empower and encourage support staff to alert them to patient’s possible psychosocial or other needs
d. PO or Practice Unit administrator assesses the competency of Practice Unit staff involved in the resource referral process at least annually. This may occur in conjunction with community agencies.
For example, practice unit staff are able to explain process for identifying and referring (or flagging for the clinical decision-maker) patients to relevant community resources
Practice Unit is able to demonstrate that training occurs as part of new staff orientation
10.5
Systematic team approach is in place for assessing and educating all patients about availability of community resources and assessing and discussing the need for referral
CHANGES are as follows
iv. In addition to screening tool and scripted conversation, supplemental Additional information about available community resources should be disseminated via language added to patient-provider partnership documents, PO or Practice Unit website, brochures, waiting room signage, county resource booklets at check-out desk, or other similar mechanisms
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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10.7
Systematic approach is in place for tracking referrals of high-risk patients to community resources made by the care team, and making every effort to ensure that patients complete the referral activity
Specialist Guidelines:
Required for PCMH Designation: NO |
Predicate Logic: n/a |
PCMH Validation Notes for Site Visits |
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12.0 Patient Web Portal
12.1
Available vendor options for purchasing and implementing a patient web portal system have been evaluated
a. Assessment of vendor options may be conducted by PO or Practice Unit.
12.2
PO or Practice Unit has assessed liability and safety issues involved in maintaining a patient web portal at any level and developed policies that allow for a safe and efficient exchange of information
PCP and Specialist Guidelines:
Safety issues may include prohibiting electronic communication for emergency situations, etc.
All messages exchanged must be secure and HIPAA compliant.
Attestation of PO is acceptable
12.4
Patients actively log and/or graph results of self-administered tests (e.g., daily blood glucose levels, blood pressure, weight)
a.b. Providers are alerted when patient logs a value outside of acceptable parameters
12.8
Patient portal system has capability for patient to create and update personal health record
a. Personal health records are created and maintained by patients to improve their health care RETIRED
13.0 Coordination of Care
Goal: Patient transitions are well-managed and patient care is coordinated across health care settings through a process of active communication and collaboration among providers, patients and their caregivers
13.1 - Required
For patient population selected for initial focus, mechanism is established for being notified of each patient admit and discharge or other type of encounter, at facilities with which the physician has admitting privileges or other ongoing relationships
PCP and Specialist Guidelines:
Standards for information exchange have been established among participating organizations to enable timely follow-up with patients.
Facilities must include hospitals, and may include long-term care facilities, home health care, and other ancillary providers.
Completing an H&P would not suffice in meeting the intent. The communication should be specific to the patient, i.e., indicating which tests should be completed prior to the visit, inquiring if the patient has specific issues that need to be discussed at the visit, and other information that would optimize the visit for both the patient and provider.
Provide examples of alerts or questionnaire
13.9
Coordination capabilities as defined in 13.1-13.7 are in place and extended to all patients that need care coordination assistance
PCP and Specialist Guidelines:
a. Written procedures and/or guidelines on care coordination processes may be developed by the PO or practice
14.0 Specialist Pre-Consultation and Referral Process
Goal: Process of referring patients from PCPs to specialists, and from specialists to sub-specialists, is well coordinated and patient-centered, and all providers have timely access to information needed to provide optimal care
11 total capabilities; 43 retired
All capabilities applicable to: Adult and Peds patients
14.1
Documented procedures are in place to guide each phase of the specialist referral process – including desired timeframes for appointment and information exchange - for all preferred or high-volume providers
14.2
Documented procedures are in place to guide each phase of the specialist referral process – including desired timeframes for appointment and information exchange – for other key providers
14.3
Directory is maintained listing specialists to whom patients are routinely referred
14.5
Practice Unit or designee ensures patients are scheduled for specialist appointments in timely manner
PCP Guidelines:
14.8
Appropriate Practice Unit staff are trained on all aspects of the specialist referral process
**
THIS CONCLUDES OUR VIDEO OF THE 2020 CHANGES. REMEMBER TO FIND FULL 2020 UPDATES WITHIN THE BCBS FILE IN THE DOCUMENTS SECTION BELOW AND THANK YOU FOR TAKING THE PCMH 2020 UPDATES.
An innovative incentive program through BCBSM that brings together physician organizations from across Michigan, to encourage information sharing about various aspects of health care. Program participants, including both primary care physicians and specialists, collaborate on initiatives designed to improve the health care system in the state.
An organization that partners with physicians or is a group of physicians that works with health plans on contracts and other mutual interests (i.e. incentive programs, transition programs, etc.) of their organization.
An organization that partners with physicians and hospitals in order to obtain payer contracts and to further mutual interests (i.e. incentive programs, transition programs, etc.) within integrated delivery systems.
An organization that is 50% owned by physicians and 50% owned by the Health System to negotiate payer contracts, assist with health plan enrollment, and provide guidance and support in mutual interests that promote evidence based care and overall well being of their customers "the patient".
Twice a year (summer and winter) BCBSM requires PO/PHO to conduct assessments for PGIP participating offices which include review of office demographic information, office technology and PCMH initiative implantation within the office. This data is linked to PCMH nomination, PCMH designations and PGIP incentive monies.
The identification of a practice within the PGIP program.
An office in PCMH nomination status is requesting review by BCBSM for PCMH Designation. An office can be nominated through their PGIP participating PO/PHO during the BCBSM Winter SRD submission.
Total number of "current" patients in the practice.
Total number of patients in the denominator with whom conversations have been held and partnerships established at any point in the past
Claim payments based on quality and utilization scoring determined by the health plan. (Quality based payment structure)