1. WHAT IS THE PATIENT-CENTERED MEDICAL HOME AND PATIENT-CENTERED MEDICAL HOME-NEIGHBOR? ..............................................................4
2. WHAT ARE CAPABILITIES? ........................................................................4
3. WHY DO WE NEED INTERPRETIVE GUIDELINES? ..........................................................5
5. WHO IS RESPONSIBLE FOR REPORTING PCMH/PCMH-N CAPABILITIES TO BCBSM? ....5
6. 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? ...........5
7. 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? ..............................................................................6
8. WHY IS IT SO IMPORTANT THAT THE CAPABILITIES BE REPORTED ACCURATELY? ........6
9. IF A PRACTICE FALLS BELOW THE 50 CAPABILITY MINIMUM OR IS FOUND TO NOT HAVE ALL CORE CAPABILITIES IN PLACE THROUGHOUT THE YEAR, THEY WILL BE AT RISK OF LOSING THEIR PCMH DESIGNATION DURING THE NEXT DESIGNATION CYCLE. THEY ARE EXPECTED TO HAVE ALL REQUIRED CAPABILITIES IN PLACE AND MEET THE MINIMUM CAPABILITY THRESHOLD COUNT BY THE NEXT FULL PCMH DESIGNATION/NOMINATION PERIOD (FALL SAD TOOL SNAPSHOT).DO WE HAVE TO IMPLEMENT THE CAPABILITIES IN ORDER? ............................................7
10. WHAT HAPPENED TO DOMAIN 7 AND WHY DOESN'T DOMAIN 8 START AT 8.1? .........7
WE HAVE AMASSED YEARS OF SELF-REPORTED DATA BASED ON NUMBERED
CAPABILITIES; WE CANNOT REASSIGN CAPABILITY NUMBERS. DOMAIN 7 WAS
PREVIOUSLY USED TO COLLECT EVIDENCE-BASED CARE DATA AND HAS BEEN
RETIRED. IN DOMAIN 8, CAPABILITIES RELATED TO E-PRESCIBING HAVE BEEN RETIRED.
CAPABILITIES IN DOMAIN 8 ARE NOT PAID THROUGH THE PCMH
CAPABILITY PAYMENT PROCESS. NOTE - ALL ACTIVE CAPABILITIES WILL COUNT
TOWARDS THE 50 MINIMUM REQUIRED CAPABILITIES. .............................................7
11. WHY DOES BCBSM PERFORM SITE VISITS AND HOW SHOULD PHYSICIAN ORGANIZATIONS PREPARE PRACTICES? ................................................................7
12. WHAT IS MEANT BY "CO-MANAGEMENT"? ..................................................................7
13. WHAT DOES THE TERM "CLINICAL PRACTICE UNIT TEAMS" MEAN? ............................8
14. HOW IS HEALTH LITERACY RELATED TO THESE GUIDELINES? .......................................8
15. WHO DO I CONTACT FOR QUESTIONS? ........................................................................8
PCMH/PCMH-N INTERPRETIVE GUIDELINES .....................................................................10
1. PATIENT-PROVIDER PARTNERSHIP ..............................................................................10
2.0 PATIENT REGISTRY .......................................................................................................15
3.0 PERFORMANCE REPORTING .......................................................................................29
3.19 38
4.0 INDIVIDUAL CARE MANAGEMENT ..............................................................................41
5.0 EXTENDED ACCESS ......................................................................................................57
6.0 TEST RESULTS TRACKING & FOLLOW-UP .....................................................................70
8.0 ELECTRONIC PRESCRIBING AND MANAGEMENT OF CONTROLLED SUBSTANCE PRESCRIPTIONS ................................73
9.0 PREVENTIVE SERVICES ................................................................................................74
10.0 LINKAGE TO COMMUNITY SERVICES .........................................................................84
11.0 SELF-MANAGEMENT SUPPORT .................................................................................89
12.0 PATIENT WEB PORTAL ...............................................................................................94
13.0 COORDINATION OF CARE ..........................................................................................97
14.0 SPECIALIST PRE-CONSULTATION AND REFERRAL PROCESS .....................................103
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)