READ ME FIRST: THE ESSENTIAL FAQS ABOUT THE PATIENT-CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME-NEIGHBOR PROGRAM ............................ 3
WHAT IS THE PATIENT-CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME-NEIGHBOR? ...................................................................................... 3
WHAT ARE CAPABILITIES? ........................................................................................... 3
WHY DO WE NEED INTERPRETIVE GUIDELINES? ......................................................... 4
WHO IS RESPONSIBLE FOR REPORTING PCMH/PCMH-N CAPABILITIES TO BCBSM? .. 4
CAN WE REPORT A CAPABILITY IN PLACE AS SOON AS THE PRACTICE HAS THE ABILITY TO USE IT? OR WHAT ABOUT WHEN ONE PHYSICIAN OR MEMBER STARTS USING IT?..................................................................................................................... 4
THE PCPS IN MY PO ARE VERY FAMILIAR WITH THE PCMH MODEL, BUT OUR SPECIALISTS HARDLY KNOW WHAT WE’RE TALKING ABOUT. SOME OF THEM THINK THEY SHOULD BE THEIR PATIENT’S MEDICAL HOME, NOT THE PCP. WHAT SHOULD WE DO ABOUT THIS? ................................................................................................... 5
WHY IS IT SO IMPORTANT THAT THE CAPABILITIES BE REPORTED ACCURATELY? ..... 5
DO WE HAVE TO IMPLEMENT THE CAPABILITIES IN ORDER? ..................................... 6
WHATHAPPENEDTODOMAIN7ANDWHYDOESDOMAIN8STARTAT8.7?...........6
WHAT DOES PCMH/PCMH-N HAVE TO DO WITH ORGANIZED SYSTEMS OF CARE?... 6
WHYDOESBCBSMPERFORMSITEVISITSANDHOWSHOULDPHYSICIAN ORGANIZATIONS PREPARE PRACTICES?...................................................................... 6
WHATISMEANTBY“CO-MANAGEMENT?”................................................................7
WHATDOESTHETERM“CLINICALPRACTICEUNITTEAMS”MEAN?..........................7
HOWISHEALTHLITERACYRELATEDTOTHESEGUIDELINES?.....................................7
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PCMH/PCMH-N INTERPRETIVE GUIDELINES....................................................................... 9
1.0 PATIENT-PROVIDERPARTNERSHIP..............................................................................9
2.0 PATIENT REGISTRY ...................................................................................................... 14
3.0 PERFORMANCE REPORTING ....................................................................................... 27
4.0 INDIVIDUAL CARE MANAGEMENT.............................................................................. 38
5.0 EXTENDED ACCESS ...................................................................................................... 55
6.0 TEST RESULTS TRACKING & FOLLOW-UP.................................................................... 64
8.0 ELECTRONIC PRESCRIBING AND MANAGEMENT OF CONTROLLED SUBSTANCE PRESCRIPTIONS.......................................................................................................... 68
9.0 PREVENTIVE SERVICES ................................................................................................ 69 10.0 LINKAGE TO COMMUNITY SERVICES ........................................................................ 78 11.0 SELF-MANAGEMENT SUPPORT................................................................................. 82 12.0 PATIENT WEB PORTAL .............................................................................................. 87 13.0 COORDINATION OF CARE.......................................................................................... 91 14.0 SPECIALIST PRE-CONSULTATION AND REFERRAL PROCESS...................................... 96
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)