Physician Practice Connections –
Patient-Centered Medical Home
(PPC-PCMH)
NCQA Recognition Workbook
© Copyright 2011 North Carolina Community Care Networks, Inc. All rights reserved. The content set forth herein is made available on an “as is” basis
without representation or warranty of any kind and solely for use and distribution by primary care physicians, without modification and only so long as the
content of this footer is reproduced on every copy thereof, in connection with the internal activities of their respective not-for-profit organizations to secure
NCQA recognition as patient-centered medical homes. All other uses of or modifications to the content set forth herein without the prior express written
approval of North Carolina Community Care Networks, Inc. are strictly prohibited. Works copyrighted by third parties and included herein are used with
the permission of the respective copyright owners in each case.
Special Thanks to American Academy of Family Physicians (AAFP), Medical Group Management Association (MGMA) and
Richard J. Barron, MD for selflessly sharing materials with us.
Special thanks, acknowledgement, and appreciation for their contributions also go to:
The PCMH Team at HealthTeamWorks: http://www.healthteamworks.org/index.aspx
Natl Ctr for Medical Home Implementation and the American Academy of Pediatrics: http://www.medicalhomeinfo.org/
Institute for HealthCare Improvement: http://www.ihi.org/ihi
Diabetes Initiative: http://www.diabetesinitiative.org/index.html
Primary Care Development Corporation: http://www.pcdc.org/
Improving Chronic Illness Care: http://www.improvingchroniccare.org/
Gateway Community Health Center: http://www.gatewaychc.com/
Robert C. Byrd Center for Rural Health at Marshall University: http://crh.marshall.edu/
Mid-State Health – NH: http://www.midstatehealth.org/
NC Academy of Family Physicians: http://www.ncafp.com/
The PCMH Team at CCNC: http://www.communitycarenc.org/
Created by:Zula Solomon, MBA – PCMH Quality Improvement Coach
Deb Barnett, RN, MS, FNP – Family Medicine Residency PCMH Project Manager
R. Scott Hammond, M.D. -- Primary Care Consultants, Inc.
Adapted and expanded by:R.W. Watkins, MD, MPH, FAAFP – Community Care of North Carolina
2
Table of Contents
Organizational Steps ___________________________________________________________________________________________ 4
Definitions ____________________________________________________________________________________________________ 5
Abbreviations _________________________________________________________________________________________________ 7
PPC-PCMH STANDARDS AND SCORING ___________________________________________________________________________ 8
PPC 1: Access and Communication
( 9 Points) ___________________________________________________________________ 10
PPC 2: Patient tracking and Registry Functions ( 21 Points) _________________________________________________________ 17
PPC 3: Care Management ( 20 Points ) ___________________________________________________________________________ 28
PPC 4: Patient Self- Management Support ( 6 Points )_______________________________________________________________ 36
PPC 5: Electronic Prescribing ( 8 Points ) _________________________________________________________________________ 41
PPC 6: Test Tracking ( 13 Points ) _______________________________________________________________________________ 46
PPC 7: Referral Tracking ( 4 Points ) _____________________________________________________________________________ 50
PPC 8: Performance Reporting and Improvement ( 15 Points ) ________________________________________________________ 52
PPC 9: Advanced Electronic Communications ( 4 Points) ____________________________________________________________ 60
3
Organizational Steps
1. Build your team
a. Establish regular meeting time
b. Delegate roles and responsibility (who will be the project manager?)
2. Establish planning time
a. Identify practice champion and block non-clinic time for the
provider(s) to do the work
3. Understand what it means to be a medical home.
a. What are the joint principles?
b. Who is NCQA and what are the standards and guidelines for PPCPCMH?
c. What is the Chronic Care Model?
4. Establish Aim and milestones
a. Create a time table
b. Identify a project manager who will hold the team accountable to meeting goals and milestones?
5. Read the workbook
6. Do the work
4
Definitions:
Allergies: Adverse reactions to substances.
Business associate: A person or organization that on behalf of a covered entity (health plan, health care clearinghouse or health care provider) or
organized health care arrangement, which includes a covered entity, performs, or assists in the performance of, but not in the capacity of a workforce
member, functions or activities involving the use or disclosure of individually identifiable health information from the covered entity or organized health
care arrangement.
Clinical visit data: A record of patient activity at the practice.
Clinically important condition: A chronic or recurring condition that a practice sees most frequently, such as otitis media, asthma, diabetes or
congestive heart failure. The most frequently seen single-episode conditions may also be clinically important conditions such as colds or urinary tract
infections.
Contact information: Patient location facts that may include telephone number, e-mail address, payor ID and emergency contact information.
Demographic information: Information that includes at least ethnicity, gender, marital status, date of birth, type of work, hours of work and preferred
language.
Diagnoses: Problem list of conditions, injuries or other health issues.
Documented process: Written statements describing the practice's procedures. The statements may include protocols or other documents that describe
actual processes or blank forms the practice uses in work flow such as referral forms, checklists and flow sheets.
Emergency admissions: Any unscheduled medical or behavioral health care event that results in either an emergency room visit or hospital admission.
Evidence-based: Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by scientific
evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion.
Evidence-based guidelines: Clinical practice guidelines that are known to be effective in improving health outcome. The effectiveness is determined by
scientific evidence or, in the absence of scientific evidence, professional standards or, in the absence of professional standards, expert opinion. See
PRACTICE GUIDELINES.
Example: One document, report or prepared material that serves as a model for those used by the practice.
Factor: An item within an element that is scored. For example, an element may require the organization to demonstrate that a specific document includes
four items. Each item is a factor.
Materials: Prepared material that the practice provides to patients, including clinical guidelines and self-management and educational resources such as
brochures, Web sites, videos and pamphlets.
Multi-Site Group: Multiple practice sites of a larger organization that provide standardized systems across the practice. In this case, NCQA reviews
some elements once and applies the results to all practice sites in the Multi-Site Group.
Must Pass elements: Designated elements that a practice must pass at a 50% or greater score to achieve Recognition.
Population management: The assessment of all patients in a practice to identify groups of patients who require specific services.
Practice: [Appears with in Interactive Survey System] One physician or a group of physicians at a single geographic location who practice together.
Practicing together means that, for all the physicians in a practice:
1) The single site is the location of practice for at least the majority of their clinical time;
5
2) The non-physician staff follow the same procedures and protocols;
3) Medical records, whether paper or electronic, for all patients treated at the practice site are available to and shared by all physicians as appropriate;
4) The same systems--electronic (computers) and paper-based--and procedures support both clinical and administrative functions: scheduling time,
treating patients, ordering services, prescribing, keeping medical records and follow-up.
Practice guidelines: Systematically developed descriptive tools or standardized specifications for care to assist practitioner and patient decisions about
appropriate health care for specific clinical circumstances. Practice guidelines are typically developed through a formal process and are based on
authoritative sources that include clinical literature and expert consensus. Practice guidelines may also be called PRACTICE PARAMETERS,
TREATMENT PROTOCOLS or CLINICAL GUIDELINES.
Preventive health data: A patient's status regarding receipt of preventive screenings, immunizations and counseling appropriate for the patient's age
and gender.
Records or files: Actual patient files or registry entries that document an action taken. The files are a source for estimating the extent of performance
against an element. There are two ways to measure this performance: 1) a query of electronic files yielding a count, and 2) the sample selection process
provided by NCQA--instructions for choosing a sample and a log for reviewing records are in the Record Review Workbook.
Registry: A searchable list of patient data that the practice actively uses to assist in patient care.
Reports: Aggregated data showing evidence of action; may include manual and computerized reports.
Risk factors: Behaviors, habits, age, family history or other factors that may increase the likelihood of poor health outcomes.
Sample: A statistically valid representation of the whole.
Treatment plan: A written action plan based on assessment data that identifies the individual or patient's clinical needs, the strategy for providing
services to meet those needs, the treatment goals and objectives.
Practice is done working on Element
Practice is focusing on this Element
Practice is choosing not to work on this Element
6
Abbreviations
Acronym
AAFP
ABFP
ABIM
ABMS
ABP
ACP
AHRQ
AMA
AQA
CAFP
CCGC
CCM
CCNC
CMS
CMS
EHR
EMR
EPIC
FPM
HIT
ICIC
IHI
IOM
IPIP
ISS
NCAFP
NCQA
NICHQ
NIH
NQF
PBM
PCM
PDSA
PHR
PPC
PPC-PCMH
QI
American Academy of Family Physicians
American Board of Family Physicians
American Board of Internal Medicine
American Board of Medical Societies
American Board of Pediatrics
American College of Physicians
Agency for Healthcare Research and Quality
American Medical Association
Ambulatory Quality Alliance
Colorado Academy of Family Physicians
Colorado Clinical Guidelines Collaborative
Chronic Care Model
Community Care of North Carolina
Colorado Medical Society
Centers for Medicare and Medicaid Services
Electronic Health Record
Electronic Medical Record
Enhancing Practice, Improving Care
Family Practice Management
Health Information Technology
Improving Chronic Illness Care
Institute for Healthcare Improvement
Institute of Medicine
Improving Performance in Practice
Interactive Survey System
North Carolina Academy of Family Physicians
National Committee for Quality Assurance
National Initiative for Children’s Health Care Quality
National Institute of Health
National Quality Forum
Pharmacy Benefit Management company
Planned Care Model
Plan Do Study Act
Personal Health Record
Physician Practice Connections
Physician Practice Connections─Patient-Centered Medical Home
Quality Improvement
Acronym
RIA/E
RMD
RMHP
TRIA
Rapid Improvement Activity/Event
Reach My Doctor
Rocky Mountain Health Plan
Tobacco Rapid Improvement Activity
7
PPC-PCMH STANDARDS AND SCORING
PCMH Elements by HIT Type
Basic
Intermediate Advanced
PPC 1 A - B PPC 2 B, C, F PPC 6 B
PPC 2 A, D, E PPC 5 A - C PPC 8 F
PPC 3 A - E PPC 8 E
PPC 4 A - B PPC 9 A - C
PPC 6 A
PPC 7 A
PPC 8 A - D
Practice can achieve a passing score on all
Must Pass Elements with Basic Health
Information Technology
Possible Status
Number of Points
Recognized – Level III
Recognized – Level II
Recognized – Level I
Not Recognized
75- 100
50-75
25- 50
0 - 25
Must Pass
Elements at 50%
Scoring Level
10 out of 10
10 out of 10
5 out of 10
0 out of 10
Of the 30 elements in PPC-PCMH, 10 are Must Pass, that is, elements that a
practice Must Pass at 50% or greater score to achieve Recognition. Practices
that achieve less than 5 Must Pass elements receive a Not Recognized
status. If there is a difference in Level achieved for the number of points and
the Must Pass elements, the practice will be awarded the lesser level. For
example, if a practice has 65 points but passes only 7 Must Pass Elements,
the practice will achieve Level 1 Recognition.
8
PPC 1
Must
Pass
Actions for Point Person
Staff
responsible
Ready for
NCQA
The person
assigned to
do the final
review
Standard
Complete
NCQA
document
linked
Element A
x
Yes
No
Yes
No
Yes
No
Element B
x
Yes
No
Yes
No
Yes
No
Element A
Yes
No
Yes
No
Yes
No
Element B
Yes
No
Yes
No
Yes
No
Element C
Yes
No
Yes
No
Yes
No
Points
Completed
Points
Pending
Upload
completed
Total Points
PPC 2
Element D
x
Yes
No
Yes
No
Yes
No
Element E
Element F
x
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
x
PPC 3
Element A
Yes
No
Yes
No
Yes
No
Element B
Yes
No
Yes
No
Yes
No
Element C
Yes
No
Yes
No
Yes
No
Element D
Yes
No
Yes
No
Yes
No
Element E
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Element A
Yes
No
Yes
No
Yes
No
Element B
Yes
No
Yes
No
Yes
No
Element C
PPC 6
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
PPC 4
Element A
Element B
PPC 5
Element A
x
x
Element B
PPC 7
Element A
PPC 8
x
Yes
No
Yes
No
Yes
No
Element A
x
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Element B
Element C
Yes
No
Yes
No
Yes
No
Element D
x
Yes
No
Yes
No
Yes
No
Element E
Yes
No
Yes
No
Yes
No
Element F
PPC 9
Yes
No
Yes
No
Yes
No
Element A
Yes
No
Yes
No
Yes
No
Element B
Yes
No
Yes
No
Yes
No
Element C
Yes
No
Yes
No
Yes
No
9
PPC 1: Access and Communication
9 Points
Intent
The practice provides patient access during and after regular business hours, and communicates with patients effectively.
Element 1A: What are your written policies for access and communication to your patients?
Element 1B: Proof that shows your practice uses polices from 1A for patient access and communication.
Who will manage this standard?
NCQA’s Example Sheet:- Standard1 examples from NCQA
PPC
1
A
B
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
x
Not started
In process
Done
Not working on this
Yes
Yes
x
Not started
In process
Done
Not working on this
Yes
Yes
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total
Points
Notes:
Element 1A: Access and Communication Processes
Must Pass
4 Points
The practice establishes in writing standards for the following processes to support patient access:
Do we have these factors in writing?
Tools/ Resources needed
Process
Owner
Due Date
10
1. Scheduling each patient with a personal
clinician for continuity of care
Yes
No
Written policy for
scheduling patients with a
requested provider.
2. Coordinating visits with multiple clinicians
and/or diagnostic tests during one trip
Yes
No
Written procedures for
staff for making
appointments/ scheduling
patient visit so that it is
one trip to get the
services they need.
Written policy for triage
on what needs to been
seen urgently.
3. Determining through triage how soon a
patient needs to be seen
Yes
No
4. Maintaining the capacity to schedule
patients the same day they call
Yes
No
Measuring capacity tool
5. Scheduling same day appointments based
on practice's triage of patients' conditions
Yes
No
Procedures
6. Scheduling same day appointments based
on patient's/family's requests
Yes
No
Open Access Article
7. Providing telephone advice on clinical
issues during office hours by physician, nurse
or other clinician within a specified time
Yes
No
8. Providing urgent phone response within a
specific time, with clinician support available 24
hours a day, 7 days a week
Yes
No
Policy on returning urgent
calls
What is your after hour’s
coverage? Sending to ER
doesn’t meet standard.
11
9. Providing secure e-mail consultations with
physician or other clinician on clinical issues,
answering within a specified time
Yes
No
Policy on checking e-mail
If using, website for appt,
rx refill, test results, etc…
what is your policy?
10. Providing an interactive practice Web site
11. Making language services available for
patients with limited English proficiency
Yes
No
Yes
No
PPC 4A asks similar communication
question.
12. Identifying health insurance resources for
patients/families without insurance.
Examples
Tools/
Resources
Yes
No
Tool: RMD if your EMR
doesn’t have this
functionality
If using, website for appt,
rx refill, test results, etc…
what is your policy?
Tool: RMD if your EMR
doesn’t have this
functionality
You don’t have to have
policy on this factor. You
just have to make a
notation in the Support
Test/Notes Box.
What percent of your
practice have limited
English proficiency?
Do you have bilingual
staff?
Resources: Language
lines (AT&T, Sprint..)
What is the nearest
CHC? Safety net clinic?
What the phone number
for Medicaid/ Medicare?
Data source: Written procedures for staff for appointments, triage and patient communication; log or schedule to demonstrate capacity (Item 3).
1. Policies and Procedures (chapter 3)
 MGMA’s - Operating Policies and Procedures: Manual for Medical Practices by Elizabeth Woodcock.
(MGMA Member $135, Joint MGMA-ACMPE member , MGMA affiliate $162.00 , Non-member $211.00)
 Practice Access Policies (examples) – (click_here)
2. Measuring Demand and Capacity
 What Works, Effective Tools & Case Studies To Improve Clinical Office Practice
by Sue Houck. HealthPress Publishing,
2004, chapters 3 and 7.
12





Same Day Appt Tally Sheet (Word doc) ( click_here)
Same Day Appt Spreadsheet (Excel doc) (click_here)
Open Access (Same Day Appts) Introduction (click_here)
Open Access Preparation (click_here)
Open Access Implementation (Instructions and Insights) (click_here)

Murray MD, Mark. Same Day Appointment: Exploding the Access Paradigm. FPM 2000 (click here)


IHI’s Demand and Capacity Diagnostic Tool (click here)
IHI.org - Shortening Waiting Times: Six Principles for Improved Access (click here)
3. Health Insurance Resources of Patients/ Families without insurance
 Community Health Centers/ Safety Net Clinics –
i. Community Resources Toolkit (http://www.pediatricmedhome.org/section3/step1/popup_resource_list.aspx )
4. Language Resources
 NC Professional Interpreters Association - http://ncpiaonline.org/
 AT&T’s Language Line (http://www.languageline.com/page/industry_healthcare )
 HealthTranslations.com (http://www.healthtranslations.com/ )
5. RMD – Activation of all of the RMD features (click here)
6. Practice Examples
PCMH 1A1 (PCMH1A1) – Scheduling Policy
PCMH 1A2 (Lakeside FP – One Stop Shop – Referral Policy) – Coordinating Care
PCMH 1A3,5 (Lakeside FP – Triage Policy) – Triage Policy
PCMH 1A4 (PCMH1A4) – Advanced Access
PMCH 1A1,4,6 (Lakeside FP – Open Access Policy) – Open Access
PCMH 1A7 (Lakeside FP – Phone Note Policy) – Phone Policy
PCMH 1A8 (Lakeside FP – On-call Policy) – On-call Policy
PCMH 1A10, 11 (PCMH 1A10, 11) – Language and Web-based Services
PCMH 1A11 (Lakeside FP – Guide to Interpreter Services) – Interpreter Services
PCMH 1A12 (Lakeside FP – Patient Advocacy Policy) – Patient Advocacy Policy
13
PCMH 1A12 (Lakeside FP – Financial Assistance Policy) – Financial Assistance Policy
Percentage
100%
Practice has written processes for 9 -12 items
75%
Practice has written processes for 7 - 8 items
50%
Practice has written processes for 4 - 6 items
25%
Practice has written processes for 2 – 3 items
0%
Practice has written processes for 0 - 1 items
Further Examples/Notes:
Min. score to pass
Our Score
X
Telephone/Email Response Policy (click here )
Scheduling, Same Day Appts, Triage, Care Coordination Policy (click here )
Access and communication Policy (click here )
Care Coordination between PCP and Specialist Policy (click here )
Practice Access and Communication Policies 2 ( click here)
Patient Portal Policies (click here ) or (click here)
Element 1B: Access and Communication Results
Must Pass
5 Points
The practice's data shows that it meets access and communication standards in 1A:
What needs to happen?
1. Visits with assigned
personal clinician for
each patient
Not started
2. Appointments
scheduled to meet
the standards in
Items 2-6 in 1A
3. Response times to
meet standards for
timely response to
telephone requests
Not started
In process
Done
Linked
Tools/ Resources
Process
Owner
Due
Date
 Patient Feedback
Card
In process
Done
Linked
 Excel Pt. Feedback
Tracking sheet
 Logs
Not started
In process
Done
Linked
 Patient Feedback
Card
14
Examples
Tools/
Resources
Percentage
100%
75%
50%
25%
0%
4. Response times to
Not started
In process
Done
Linked
 can exclude patient
that don’t have
meet its standards for
email
timely response to email and interactive
Web requests
5. Language services
Not started
In process
Done
Linked
 can mark NA if
language services
for patients with
aren’t required
limited English
proficiency.
Tracking reports, either paper or screen shots, showing records for a period of appointments with personal clinicians, average wait for
appointments, average time for returning telephone calls and emails.
 Visits with assigned physician
 Timely response to phone, e-mail and Internet requests
 Language services if the practice’s population requires it
1. Patient Satisfaction Survey
Patient Feedback Card (click here) & Excel Tracking Sheet (click here) For a more in-depth survey (click here )
For making sure patients are being seen in a timely manner use the Patient Cycle Tool (click here )
2. Logs
 3rd next available appointment, no show, telephone response time, # of same day appointments available, fill rate, ..etc (click here) Also
see below for more examples.
 Open Access information - https://www.aap.org/visit/keymeasures.htm
 Supply Demand worksheet - click here For an example ( click here)
3. Reports from “How’s your Health” www.howsyourhealth.org
4. Article:- Getting the most of your phone system (click here )
5. Panel Size How Many Patients Can a Provider Handle (click here )
Min. score to pass
Practice data meets 5 items
Practice data meets 4 items
Practice data meets 3 items
X
Practice data meets 2 items
Practice data meets 0-1 items
Our Score
15
Practice Examples/Notes:
PCMH 1B1 – Personal Physician (..\Practice Examples\Lakeside FP\PPC1B-1-LO Personal Clinician.pdf )
( ..\Practice Examples\Elizabeth FP\1B_1_Elizabeth[1].pdf)
PCMH 1B2 – Same Day Log (..\Practice Examples\Lakeside FP\PPC1B-2 Same Day Log LO.pdf )
( ..\Practice Examples\Lakeside FP\PPC1B-2-LO-Minimized-Trips.pdf)
(..\Practice Examples\Lakeside FP\PPC1B-2-LO-Same Day Appointment Scheduled.pdf )
(..\Practice Examples\Elizabeth FP\1B_2_Elizabeth_Family.pdf )
PCMH 1B3 – Language Services (..\Practice Examples\Lakeside FP\PPC1B-5-LO-Language Services.pdf )
(..\Practice Examples\Elizabeth FP\1B_5_Elizabeth[1].pdf )
( LanguageServicesPolicy)
PCMH 1B5 – Phone Turn-Around Time ( ..\Practice Examples\Lakeside FP\PPC1B-3 LO Phone Note.pdf)
(..\Practice Examples\Lakeside FP\PPC1B-3 Telephone Response Log LO.pdf )
(..\Practice Examples\Lakeside FP\PPC1B-3 Telephone Response Log Summary.pdf )
(..\Practice Examples\Elizabeth FP\1B_3_Elizabeth.pdf )
16
PPC 2: Patient tracking and Registry Functions
21 Points
The practice systematically manages patient information and uses the information for population management to support patient care.
Intent
The practice has readily accessible, clinically useful information on patients that enables it to treat patients comprehensively and systematically.
Element 2A: The practice has the ability to query basic patient demographic information
Element 2B: The report from the query in 2A
Element 2C: The practice has the ability to query & report patient clinical information
Element 2D: Flowsheet and/ or templates used to organize and document clinical information such as problem lists, medication lists, and risk factors
Element 2E: For patients that have Diabetes, CVD, and Low back pain, can your practice identify: # of patient with condition, # of visits, total fees billed or
cost associated with the risk factor
Element 2F: Practice uses electronic information to generate lists of patients and remind patients and clinicians of services needed
Who will manage this standard?
NCQA’s Example Sheets:- Standard2summaryNCQA , Standard2A2 , Standard2D1 , Standard2D2
PPC
2
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total Points
A
B
C
D
X
E
X
F
Notes:
17
Element 2A: Basic System for Managing Patient Data
2 Points
The practice uses an electronic data system for patients that includes the following searchable patient information:
Can we search by this
field?
1. Name
Yes
No
2. Date of birth
Yes
No
3. Gender
Yes
No
4. Marital status
Yes
No
5. Language preference
Yes
No
6. Voluntarily self-identified race/ethnicity
Yes
No
7. Address
Yes
No
9. E-mail Address (or “none” for pts)
Yes
No
10. Internal ID
Yes
No
If no, what needs to happen?
Process
Owner
Due Date
NA
8. Telephone (primary contact number)
Your internal tracking number (ie Chart #)
11. External ID
Yes
No
12. Emergency contact information
Yes
No
13. Current and past diagnoses
Yes
No
14. Dates of previous clinical visits
Yes
No
15. Billing codes for services
Yes
No
16. Legal guardian
Yes
No
17. Health insurance coverage
Yes
No
18. Patient/family preferred method of
communication.
Yes
No
NA
18
Reports from electronic systems
 You need to have numerators and denominators for this factor
 You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document
 A report of patients seen in the last 3 months that have these fields completed.
o Practices with EMRs it might be helpful to contact your vendor to run this report.
o Think of factors that are “required” fields.
Percentage
Min. score to pass
Our Score
100%
12-18 items were entered for 75 -100% of patients
75%
8-11 items were entered for 75 -100% of patients
50%
6-7 items were entered for 75 -100% of patients
X
25%
4-5 items were entered for 75 -100% of patients
0%
0-3 items were entered for 75 -100% of patients
Practice Examples/Notes:
Examples
Tools/
Resources/
Tips
PCMH 2A – Demographic Data Management ( ..\Practice Examples\Lakeside FP\PPC2A Managing Patient Data Summary.pdf)
( ..\Practice Examples\Lakeside FP\PPC2A-9-Email Capacity.pdf)
(..\Practice Examples\Elizabeth FP\2A_Elizabeth_Family.pdf )
19
Element 2B: Electronic System for Clinical Data
3 Points
The practice’s clinical data system or systems to manage care of patients include the following clinical patient information in searchable data fields:
Can we search by
this field?
1. Status of age-appropriate preventive
services (immunizations, screenings,
counseling)
Yes
No
2. Allergies and adverse reactions
Yes
No
3. Blood pressure
Yes
No
4. Height
Yes
No
5. Weight
Yes
No
6. Body mass index (BMI) calculated
Yes
No
7. Laboratory test results
Yes
No
8. Presence of imaging results
Yes
No
Yes
No
Yes
No
Yes
No
If no, what needs to happen?
Process
Owner
Due
Date
(Under 18- BMI is percentile plotted on growth chart)
9. Presence of pathology reports
10. Presence of advance directives.
11. Head circumference for patients 2 years or
younger
Examples
NA
Screen shots or reports showing fields in patient records. Where applicable, these fields may show that the patient has no allergies or lab or imaging
tests.
20
Tools/
Resources/
Tips



For items 7-10, data may indicate the presence of a written report not in the system
Website for head circumference and growth charts from CDC: http://www.cdc.gov/GrowthCharts/
Website for advanced directives for NC residents: http://www.caringinfo.org/files/public/ad/NorthCarolina.pdf
Percentage
100%
System has 9 – 11 data fields
75%
System has 7 - 8 data fields
50%
System has 5 - 6 data fields
25%
System has 3 - 4 data fields
0%
System has 0 - 2 data fields
Examples/Notes:
Min. score to pass
Our Score
X
Website for EHR and meaningful use with examples of some of the above data fields:
http://boltwebsolutions.com/clients/UniEHR/UniEHRUsersGuidetoMeaningfulUse.pdf
(This does not constitute any endorsement of any particular EHR program)
21
Element 2C: Use of Electronic Clinical Data
3 Points
The practice uses the fields listed in 2B consistently in patient records.
Factors from 2B
What is our percentage of these
measures for patients see in the last 3
months?
Tools
Process
Owner
Due
Date
1. Status of age-appropriate preventive services
Report from
(immunizations, screenings, counseling)
your EMR
or
2. Allergies and adverse reactions
NCQA
Excel
3. Blood pressure
Spreadsheet
4. Height
5. Weight
Please note:
6. Body mass index (BMI) calculated
This is a readonly example for
7. Laboratory test results
educational
8. Presence of imaging results
purposes. Use
9. Presence of pathology reports
your RRWB
10. Presence of advance directives.
from NCQA
Survey Tool.
11. Head circumference for patients 2 years or
younger
Reports from electronic systems
Examples
 You need to have numerators and denominators for this factor.
Tools/ Resources
 This element isn’t condition specific but if you use the same patients that are required for PPC 2C, 2D, 3D, and 4B it would make it
easier on your practice
 You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document
 A report of patients seen in the last 3 months that have these fields completed.
o Practices with EMRs it might be helpful to contact your vendor to run this report.
 If your EMR, billing, registry, practice management system doesn’t pull this type of information, you can do chart pulls on 36 pts.
o 1st have screen shots of where the information is entered
o 2nd use NCQA’s Excel Spreadsheet( click here) (use the same 36 pts that are required for PPC 2C, 2D, 3D, and 4B to make
it easier on your practice) For an educational PPT on the use of your RRWB ( click here)
Percentage
Min. score to pass
Our Score
100%
75 -100% of patients seen in last 3 months have at least 7 fields completed
75%
50 - 74% of patients seen in last 3 months have at least 7 fields completed
50%
25 – 49% of patients seen in last 3 months have at least 7 fields completed
25%
10 - 24% of patients seen in last 3 months have at least 7 fields completed
X
0%
Less than 10% of patients seen in last 3 months have at least 7 fields completed
Notes:
22
Element 2D: Organizing Clinical Data
Must Pass
6 Points
The practice uses the following electronic or paper-based charting tools to organize and document clinical information in the medical record:
Do you currently have a place in your chart (paper or electronic)
for these items?
1. Problem lists
Yes
3. Lists of prescribed
medications including both
chronic and short-term
4. Structured template for
age-appropriate risk factors
(at least 3)
5. Structured templates for
narrative progress notes
Examples
Tools/
Resources
Yes
Yes
No
Yes
No
Yes
No
No
Risk #1:__________ ___Flowsheets, templates or screen shots
Risk #2:_____________ Flowsheets, templates or screen shots
Risk #3:_____________ Flowsheets, templates or screen shots
Yes
Report from
your EMR
or
NCQA Excel
Spreadsheet
No
Flowsheets, templates or screen shots
Yes
Due Date
No
Flowsheets, templates or screen shots
Yes
Process
Owner
No
Flowsheets, templates or screen shots
2. Lists of over-the-counter
medications, supplements
and alternative therapies
Tools
No
Yes
Yes
Yes
No
No
No
Please note:
This is a
read-only
example for
educational
purposes.
Use your
RRWB from
NCQA
Survey Tool.
Flowsheets, templates or screen shots
Yes
No
6. Age appropriate
Yes
No
standardized screening tool
for developmental testing
Flowsheets, templates or screen shots
Yes
No
7. Growth charts plotting
Yes
No
height, weight, head
circumference and BMI, if
Flowsheets, templates or screen shots
Yes
No
less than 18 years.
Medical record review or system report showing percent of patients seen in past 3 months with information documented in at least 3 charting tools
 Screen shots of templates/ flowsheets that contain these data fields in your chart or EMR.
 You need to have numerators and denominators for this factor.
 This element isn’t condition specific but if you use the same patients that are required for PPC 2C, 2D, 3D, and 4B it would make it easier
on your practice
 You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document
 A report of patients seen in the last 3 months that have these fields completed.
o Practices with EMRs it might be helpful to contact your vendor to run this report.
 If your EMR, billing, registry, practice management system doesn’t pull this type of information, you can do chart pulls on 36 pts.
23
o
o
Percentage
100%
75%
50%
25%
0%
1st have screen shots of where the information is entered
2nd use NCQA’s Excel Spreadsheet( click here) (use the same 36 pts that are required for PPC 2C, 2D, 3D, and 4B to make it
easier on your practice) For an educational PPT on the use of your RRWB ( click here)
Min. score to pass
Our Score
75 -100% of patients seen in last 3 months have at least 3 tools with information documented.
50 - 74% of patients seen in last 3 months have at least 3 tools with information documented.
25 – 49% of patients seen in last 3 months have at least 3 tools with information documented.
X
10 - 24% of patients seen in last 3 months have at least 3 tools with information documented.
Less than 10% of patients seen in last 3 months have at least 3 tools with information
documented.
Examples/Notes:
Another example of the PCC-PCMH workbook from Elizabeth FP (click here)
Another example of the PCC-PCMH workbook from Lakeside FP (click here)
Examples of screen shots: Adult Weight Screening
Allergy List
Clinical Quality Measures - Vaccinations
Problem List
Weight/BMI, Blood Pressure charts (less than 21 years old) – (click here)
Growth Charts - (click here)
Developmental Surveillance and Screening Policy Implementation Project (D-PIP) (click here)
Developmental Screening Toolkit (click here)
Birth and Development ( click here)
Development Screening Algorithm (click here)
Early Intervention Referral Form (click here)
Medication Reconciliation Form (click here)
Patient Meds, Supplements Form (click here)
Element 2E: Identifying Important Conditions
Must Pass
4 Points
24
The practice uses an electronic or paper-based system to identify the following diagnoses and conditions:
Can you run a report in your billing system or your EMR to
get the following information?
1. Practice’s most frequently seen
diagnoses
Examples
Tools/
Resources
 Dx practice sees most often may include single
episode conditions (colds, UTI, or chronic conditions).
o # of patients with condition/ problem/ risk
factors
o # of visits for the condition or problems
o High cost (billed) conditions, problems, or
risk factors
Tools/
Resources
needed
Process
Owner
Due
Date
Reports from
billing/ Practice
management
system, or EMR
2. Most important risk factors in the
 Community based demographic characteristics
practice’s patient population
3. Three conditions that are clinically
 Chronic or recurring condition practice sees
important in the practice’s patient
o Most patients, visits, greatest cost,
population.
amendable to care management
Reports from EHR, PM system, billing system or scheduling system to query patients with Diabetes, Hypertension and Hyperlipidemia.
1. Examples might be: Diabetes, Low Back Pain, and Cardiovascular Disease as the 3 clinically important conditions for the practices.
2. In the Support Text/Notes the practice states, the three clinically important conditions. Either in a document or in the Support Text box the
practice explains or shows the data used to select the conditions. The clinically important conditions are chronic or recurring conditions that the
practice sees such as otitis media, asthma, diabetes or congestive heart failure.
Wording for “Support Text/ Notes” on the PPC-PCMH Interactive Survey System - As part of a National PCMH Demonstration Project and in
collaboration with NCQA, the Demonstration Project Stakeholders have chosen Diabetes, Hypertension and Hyperlipidemia as Clinically
Important Conditions which represent the best likelihood of being amenable to care management and providing value on costs to the health
care system based on regional experience. These conditions have associated required metrics which will be reported by the physician
practices as part of the National PCMH Demonstration Project. Some practices may chose to exchange one of the clinically important
conditions with a condition that meets the standards established on page 19 of the PPC-PCMH Standards and Guidelines.
Percentage
Min. score to pass
100%
Practice identifies 3 items
75%
Practice identifies 2 items
50%
Practice identifies 1 items
X
25%
No scoring option
0%
Practice identifies 0 items
Examples/Notes: (Community Based Demographics – Stanly County )
(State of the County Report Stanly County ) – there are usually reports available for all counties in NC
Our Score
( Top 15 Diagnoses – Elizabeth FP)
25
(Community Health Risks – Elizabeth FP )
( 2E3 - 3Top Health Conditions – Elizabeth FP)
(2E2 – BRFSS Report Adult – Elizabeth FP )
Element 2F: Use of System for Population Management
3 Points
The practice uses electronic information to generate lists of patients and take action to remind patients or clinicians proactively of services needed, as
follows:
What is our current status?
What needs to happen?
Examples
Tools/ Resources needed
1. Patients needing pre-visit planning
(obtaining tests prior to visit, etc.)
Flowsheets, templates or screen shots
Yes
No
EMR/RMD Flowsheet & CarePlan
screen
2. Patients needing clinician review
or action
Flowsheets, templates or screen shots
Yes
No
EMR/RMD Flowsheet & CarePlan
screen
3. Patients on a particular medication
Flowsheets, templates or screen shots
Yes
No
4. Patients needing reminders for
preventive care
Flowsheets, templates or screen shots
Yes
No
EMR/RMD Flowsheet & CarePlan
screen
5. Patients needing reminders for
specific tests
Flowsheets, templates or screen shots
Yes
No
RMD Patient handout
6. Patients needing reminders for
follow-up visits such as for a chronic
condition
Flowsheets, templates or screen shots
Yes
No
Screen shot of reminder email to
patients/ copy of letters to patients
7. Patients who might benefit from
care management support.
Flowsheets, templates or screen shots
Yes
No
Process
Owner
Due Date
The practice provides computerized reports or screen shots and one of the following two options showing use of information in the reports:
26
A written description of the process
Examples of use of the reports (see the bulleted list in the details).
 Identify all patients who are taking a medication for which the practice received a warning.
 Identify all patients with ischemic vascular disease not taking appropriate medication.
 Identify all children with developmental delay
 Identify all children and adolescents with asthma
 Identify all women over 50 who are due for a mammogram
 Identify all adult patients with elevated LDL for whom appropriate medication has not been prescribed
Tools/
Resources
1. Lists generated -- reports from EHR, registries, billing systems
2. RMD
a. Guideline at Point of Service (Care Plan)
b. List of patients (click here)
c. Population management reports (RMD Diabetes Summary Report)
d. Patient handout
e. DM Flowsheet, Prevention Flowsheet
Percentage
100%
Practice used information to take action on 5 – 7 items
75%
Practice used information to take action on 3 – 4 items
50%
Practice used information to take action on 1 - 2 items
25%
No scoring option
0%
Practice does not use information to take action
Examples/Notes:
Min. score to pass
Our Score
X
PCMH 2F1 - ( ..\Practice Examples\Lakeside FP\PPC2F-1 Previsit Planning.pdf)
PCMH 2F1,2,7 – (..\Practice Examples\Lakeside FP\PPC2F-1,2,7 Heart and Wellness Report.pdf )
PCMH 2F2,7 – ( ..\Practice Examples\Lakeside FP\PPC2F-2,7 DSME Report Sentout.pdf)
PCMH 2F2,7 ( ..\Practice Examples\Lakeside FP\PPC2F-2,7 Population Mngmt H&W Path.pdf)
PCMH 2F2,7 – (..\Practice Examples\Lakeside FP\PPC2F-2,7-DSME Report Inhouse.pdf )
PCMH 2F4 – (..\Practice Examples\Lakeside FP\PPC2F-4 Preventive Reminder Report.pdf )
PCMH 2F4,5 – (..\Practice Examples\Lakeside FP\PPC2F-4,5 Primary Preventive Care.pdf )
PCMH 2F4,5,6 - ( ..\Practice Examples\Lakeside FP\PPC2F-4,5,6 Reminder Call.pdf)
PCMH 2F5 – (..\Practice Examples\Lakeside FP\PPC2F-5 HgA1C Reminder Report.pdf )
PCMH 2F6 – (..\Practice Examples\Lakeside FP\PPC2F-6 Chronic Condition Reminder Report.pdf )
PCMH 2F6 – ( ..\Practice Examples\Lakeside FP\PPC2F-6 Flu Vaccination Reminder Report.pdf)
Example of a Pre-visit Contact form ( Previsit Contact Form)
PCMH 2F7 - (ChronicPainManagementFlowsheet )
27
PPC 3: Care Management
20 Points
The practice systematically manages care for individual patients according to their conditions and needs, and coordinates patients' care.
Intent
The practice maintains continuous relationships with patients by implementing evidence-based guidelines and applying them to the identified needs of
individual patients over time and with the intensity needed by the patients.
• Element 3A: The practice has evidence based clinical guidelines and is used.
• Element 3B: Practice uses paper or electronic guideline-based alerts and reminders for providers to write orders and conduct assessments when seeing
patients
• Element 3C: Practice uses non-physician staff to manage patient care
• Element 3D: Practice has a care management plan for patients with clinically important conditions
• Element 3E: Practice coordinates care and follow up for patients who receive care in inpatient and outpatient facilities
Who will manage this standard?
NCQA’s Example Sheet:- Standard3
PPC
3
A
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total Points
X
B
C
D
E
Notes:
28
Element 3A: Guidelines for Important Conditions
Must Pass
3 Points
The practice adopts and implements evidence-based diagnosis and treatment guidelines for:
What is our current
status?
Examples
Tools/
Resources
Percentage
100%
75%
50%
25%
0%
What needs to happen?
Tools/ Resources
needed
Process Owner
1. First clinically important condition
2. Second clinically important condition
3. Third clinically important condition.

Workflow organizers, which demonstrate both adoption and implementation of guidelines by the practice.

Paper-based organizers–algorithms for developing treatment plans, flow sheets or templates for documenting progress.

Electronic system organizers (registry, EHR or other system)–screenshots showing templates for treatment plans and documenting
progress.
1. Provide source of guidelines – link takes you to HealthTeamWorks website, then click on guidelines. Other resources are available there as
well.
a. Diabetes { CCGC Diabetes Guidelines}
b. CVD { CCGC CVD/Stroke Prevention Guidelines}
c. Prevention { CCGC Prevention Guidelines}
d. Depression { CCGC Depression Guidelines)
e. Asthma { CCGC Asthma Guidelines }
f. Low Back Pain { ICSI Guidelines for low back pain)
2. The links below take you to AAP’s National Center for Medical Home Implementation for Guidelines, Tools, Registry, and Protocols
a. ADHD (NCMHI ADHD Guidelines)
b. Asthma (NCMHI Asthma Guidelines)
c. Childhood Obesity (NCMH IChildhood Obesity Guidelines)
d. Special Needs Children (NCMHI Special Needs Children Guidelines)
e. Gastroenteritis (NCMHI Gastroenteritis Guidelines)
f. Safe and Healthy Beginnings/Hyperbilirubinemia (NCMHI Healthy Beginnings Guidelines)
3. Paper flow sheets, templates for documenting progress
a. Diabetes { Diabetes flowsheet version 1}, { Diabetes Flowsheet Version 2}
b. CVD
c. Prevention { CCGC Prevention Flowsheet)
d. Depression {CCGC Depression Flowsheet--Adult}
e. Asthma { CCGC Asthma Flowsheet }
f. Low Back Pain
4. Screen shots showing templates/ flowsheets for treatment plans and documenting progress.
Min. score to pass
Our Score
Practice implements guidelines for 3 conditions
No scoring options
Practice implements guidelines for 2 conditions
X
Practice implements guidelines for 1 conditions
Practice does not implements guidelines for any conditions
29
Examples/Notes:
PCMH 3A,D - (..\Practice Examples\Lakeside FP\PPC3A,D NCQA Slide.pdf )
PCMH 3A,D - (..\Practice Examples\Lakeside FP\PPC3A,D NCQA Clinical Outcome Data.pdf )
PCMH 3A1 - ( ..\Practice Examples\Lakeside FP\PPC3A-1-DXA Pathway.pdf)
PCMH 3A1 – (..\Practice Examples\Elizabeth FP\PPC_3A_1_diab_adult.doc )
PCMH 3A2 - ( ..\Practice Examples\Lakeside FP\PPC3A-2-DSME Pathway.pdf)
PCMH 3A2 – (..\Practice Examples\Elizabeth FP\PPC_3A_2_Asthma_adult_and_peds.pdf )
PCMH 3A3 – ( ..\Practice Examples\Lakeside FP\PPC3A-3-H&W Path.pdf)
Asthma Toolkit (Asthma Management Toolkit )
Diabetes Toolkit (Diabetes Management Toolkit )
Mental Health/Substance Abuse Toolkit (Mental Health/Substance Abuse Toolkit )
Element 3B: Preventive Service Clinician Reminders
4 Points
The practice uses a paper-based or electronic system with guideline-based reminders for the following services when seeing the patient:
What is our current
status?
What needs to happen?
Tools/ Resources
needed
Process Owner
1. Age-appropriate screening tests
Examples
Tools/
Resources/
Tips
2. Age-appropriate immunizations (e.g.,
influenza, pediatric)
3. Age-appropriate risk assessments (e.g.,
smoking, diet, depression)
4. Counseling (e.g., smoking cessation).
Reports, screen shots or paper flow sheets showing how the reminders are available to clinicians during the visit

Documentation from an electronic system may include reports or screen shots.

Documentation from a paper-based system may include templates, flow sheets, algorithms or reminders.

The practice must show that its clinicians have available decision support for interactions with patients including in-person appointments,
telephone calls and e-mail communication.
1. Paper based practices: Flowsheet/ template that reminds providers to check for risk assessments, immunizations, screening tests.
a. Example: Incorporation of flowsheet use detailing prevention activities and when due { CCGC Prevention Flowsheet }
2. Electronic based practices: screen shot of health maintenance screen.
3. Example of a Health Risk-Maintenance Questionnaire ( click here)
Percentage
100%
75%
50%
25%
0%
Min. score to pass
Practice uses reminders for 4 items
Practice uses reminders for 3 items
Practice uses reminders for 2 items
Practice uses reminders for 1 items
Practice uses reminders for no items
Our Score
X
30
Examples/Notes:
PCMH 3B1,2,3,4 – ( ..\Practice Examples\Lakeside FP\PPC3B-1,2,3,4 LO BS.pdf)
PCMH 3B2 – ( ..\Practice Examples\Lakeside FP\PPC3B-2-Vacc Reminders.pdf)
For guidelines for immunizations for men (click here)
For guidelines for immunizations for women (click here)
National Newborn Screening Test Report (click here)
Pediatric/Youth Symptom Checklist (click here)
Self-Assessment – Tobacco, Activity, Diet (click here)
Fitness screening tool – (click here)
Fitness screening tool (Spanish) – (click here)
Behavioral Health Assessment – Diabetes – (click here )
Depression Screening Tool (PHQ-9) in English – (click here )
Depression Screening Tool (PHQ-9) in Spanish – (click here )
Element 3C: Practice Organization
3 Points
The care team manages patient care in the following ways:
What is our current status?
Examples
Tools/
Resources/
Tips
1. Non-physician staff remind patients
of appointments and collect information
prior to appointments
2. Non-physician staff execute
standing orders for medication refills,
order tests and deliver routine
preventive services
3. Non-physician staff educate
patients/families about managing
conditions
4. Non-physician staff coordinates care
with external disease management or
case management organizations.
Job descriptions, protocols, written standing orders
What needs to happen?
Tools/ Resources
needed
Process Owner
Peds Ex: ( click here)
Adult Ex: ( click here)
See below
See below
Local Agency Referral
Form (click here )
1. Team-Based Care: Using Huddles
a. Huddle video (http://www.youtube.com/watch?v=Wttxm7jAnb4)
b. Article: Stewart, EE et. al. (2007). Huddles Improve Office Efficiency in Mere Minutes. FPM. { Article }
c. Huddle worksheet {click here }
d. Article: Bodenheimer, T. et al. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine (5):457- 461.
2. Job Descriptions
a. Article: Capko. (2007). Get Better Results with Staff Performance Standards. FPM. { PDF }
{ PDF}
31
3. Protocols
Examples of diabetes clinical protocols addressing glycemic control (medications), cardiovascular risk reduction, and health maintenance/disease
prevention. (http://www.med.unc.edu/im/staff/clinic/programs/diabetes/protocols?searchterm=None )
4. Standing Orders
a. Example of interactive page to set-up diabetes standing orders {ACP Diabetes Standing Orders}
b. Immunization standing orders {Immunization Action Coalition Standing Orders--weblink}
c. Article: Escobedo. (2002). Rethinking Refills. FPM {article PDF} Refill Protocol from the Article ( click here) (some Medication(s) on
this list like Salmeterol and Serzone may need to be removed. Please review the list before using this protocol)
Min. score to pass
Our Score
Staff manages 4 items
Staff manages 3 items
Staff manages 2 items
X
No scoring options
Staff manages 0-1 items
Percentage
100%
75%
50%
25%
0%
Examples/Notes:
PCMH 3C1-4 – (..\Practice Examples\Lakeside FP\PPC3C-1-4 DSME Pathway.pdf )
PCMH 3C2 – (..\Practice Examples\Lakeside FP\PPC3C-2 Med Refill Standing Order AV, LO, SP.pdf )
PCMH 3C2 – (..\Practice Examples\Lakeside FP\PPC3C-2 Standing O Flu LO.pdf )
PCMH 3C2 – (..\Practice Examples\Lakeside FP\PPC3C-2 Standing O Imaging LO.pdf )
PCMH 3C2-4 – ( ..\Practice Examples\Lakeside FP\PPC3C-2,3,4 DXA Pathway.pdf)
PCMH 3C – ( ..\NCQA\2011-05 (May)\PCMH3CRRWB.pdf)
Standing Orders Example – (click here )
Standing Orders Example – ( click here)
Partnering in Self-Management Support – A Clinician’s Toolkit - (click here )
Diabetes Initiative – Tremendous website for all kinds of tools for diabetes management for clinicians and staff – (click here )
Diabetes Self-Management Tool – Spanish – (click here )
NC Centers for Hospice and End of Life Care (click here)
Element 3D: Care Management for Important Conditions
5 Points
For the three clinically important conditions, the physician and non-physician staff use the following components of care management support:
What is our current status?
What needs to happen?
1. Conducting pre-visit planning with clinician reminders
2. Writing individualized care plans
3. Writing individualized treatment goals
4. Assessing patient progress toward goals
5. Reviewing medication lists with patients
6. Reviewing self-monitoring results and incorporating them
into the medical record at each visit
7. Assessing barriers when patients have not met treatment
goals
Tools/ Resources
needed
Process
Owner
Due Date
NCQA Excel
Spreadsheet
Please note: This is
a read-only example
for educational
purposes. Use your
RRWB from NCQA
Survey Tool.
32
Examples
8. Assessing barriers when patients have not filled, refilled or
taken prescribed medications
9. Following up when patients have not kept important
appointments
10. Reviewing longitudinal representation of patient’s historical
or targeted clinical measurements
11. Completing after-visit follow-up
Medical record showing the components of care management
• Patient record shows Care plans, treatment goals, progress assessments, review of home monitoring results, barriers addressed
Item descriptors:
2. Written care plan—addresses respective responsibilities of the medical home and specialists the patient is referred to.
7-8. Barriers—include the patients’ lack of understanding, motivation, financial need, insurance issues, or transportation problems.
9. Important appointments—those that the practice has requested be made in order to follow standards of care.
10. Longitudinal patient data—Graphs or flowsheets showing clinical measures (LDL, BP, wt.) over time.
11. After visit follow-up—Examples may include checking to see if the patients filled a prescription or received care by the referred consultant.
Tools/
Resources
1. NCQA Medical Record Review Worksheet or report from electronic system showing percent of patients seen with at least 4 care management
processes documented
 Screen shots of templates/ flowsheets that contain these data fields in your chart or EMR.
 You need to have numerators and denominators for this factor.
 This element isn’t condition specific but if you use the same patients that are required for PPC 2C, 2D, 3D, and 4B it would make it easier
on your practice
 You don’t have to have one report that has all of these factors but it would be helpful when you are uploading the document
 A report of patients seen in the last 3 months that have these fields completed.
o Practices with EMRs it might be helpful to contact your vendor to run this report.
 If your EMR, billing, registry, practice management system doesn’t pull this type of information, you can do chart pulls on 36 pts.
o 1st have screen shots of where the information is entered
nd
2 use NCQA’s Excel Spreadsheet( click here) (use the same 36 pts that are required for PPC 2C, 2D, 3D, and 4B to make it easier on
your practice) For an educational PPT on the use of your RRWB ( click here)
2. Diabetes sick day management http://www.mayoclinic.com/health/diabetes-management/DA00110
3. Copy of RMD’s Patient handout
4. Patients using RMD’s patient portal - www.reachmydoctor.com , Example Portal Policy (click here ) or (here)
5. Self-Management Task Communication Log {PDF}
Percentage
100%
75%
6. NC Health and Wellness Trust Fund - http://www.healthwellnc.com/
7. Develop and refine motivational interviewing skills—
a. NC Practice Improvement Collaborative http://www.ncpic.net/2010/what-is-motivational-interviewing/
b. Motivational Interviewing Roadmap { http://www.healthteamworks.org/guidelines/motivational-interviewing.html }
8. Consider “Teamlet” Model of Care—Health Coaches – see above
Min. score to pass
75% of more of patients seen in the past 3 months have at least 4 items documented
50 – 74% of more of patients seen in the past 3 months have at least 4 items documented
Our Score
33
50%
25 – 49 % of more of patients seen in the past 3 months have at least 4 items documented
25%
11 – 24 % of more of patients seen in the past 3 months have at least 4 items documented
0%
Less than 10% of patients seen in the past 3 months have at least 4 items documented
Examples/Notes:
X
PCMH 3D – (..\NCQA\2011-05 (May)\PCMH3DMedManagement.pdf )
Pre-appointment Questionnaire – (click here)
Previsit Contact Form ( click here)
Action Plan to help patients prioritize problems ( click here)
Family Centered Care Coordination Worksheet - (click here )
Pediatric Care Plan - ( click here)
Post Visit Survey - (click here )
Medication List for staff to review with Patients (click here )
Assessment of Primary Care Resources and Supports for Chronic Disease Self Management (PCRS) (click here )
Missed Appt Letter Examples (click here )
Goals and Promises Worksheet (click here )
Early Intervention Referral Form (click here )
Guidelines and Treatment of Pediatric Obesity ( click here)
Element 3E: Continuity of Care
5 Points
The practice on its own or in conjunction with an external organization engages in the following activities for patients who receive care in inpatient or
outpatient facilities or patients who are transitioning to other care:
What is our current status?
What needs to happen?
Tools/ Resources
needed
Process
Owner
Due Date
1. Identifies patients who
receive care in facilities
2. Systematically sends
clinical information to the
facilities with patients as
soon as possible
3. Reviews information from
facilities (discharge summary
or ongoing updates) to
determine patients who
require proactive contact
outside of patient-initiated
34
Examples
visits or who are at risk for
adverse outcomes
4. Contacts patients after
discharge from facilities
5. Provides or coordinates
follow-up care to
patients/families who have
been discharged
6. Coordinates care with
external disease
management or case
management organizations,
as appropriate
7. Communicates with
patients/families receiving
ongoing disease
management or high risk
case management
8. Communicates with case
managers for patients
receiving ongoing disease
management or high risk
case management
9. For patients transitioning
to other care, develops a
written transition plan in
collaboration with the patient
and family
10. Aids in identifying a new
primary care physician or
specialists or consultants and
offers ongoing consultation.

May be from the practice itself or from an external case management organization such as a disease management organization with
which the practice works. The data sources may include:

Policies/protocols that include the practice’s timeframe for patient follow up after an admission or emergency room visit

Policies/protocols for using care plans and patient visit flow sheets

Printout from registry, EHR, hospital emergency room, admitting department or other computerized reports that include a list of
identified patients, emergency room visits and inpatient admissions

Paper or electronic communication forms/tools to use with external facility regarding patient clinical information.

Manual or electronic patient health/needs assessments

Blinded case management or medical record notes.

Policies and medical record documentation detailing proactive outreach to patients receiving care at another facility (inpatient or
outpatient) to ensure that the patient receives appropriate follow-up care.

Follow-up care can include physician counseling and/or referrals to community resources, disease management programs, or selfmanagement support programs.
35
Tools/ Resources
1. Screen shot of RMD’s CareNotes or CareTeam (click here) or (here)
2. Example ER follow-up log (click here) or you can adapt the tracking log (click here )
3. Care Transitions resources
• an HMO workgroup report on Care Management—excellent background information and resource to operationalize “Care
Management” { click here }
• “The Care Transitions Program” affiliated with UCHSC: www.caretransitions.org
• Relevant articles
•
Sylvester, I. et al. (2008). Transforming your practice—what matters most. Family Practice Management, 15(1). (PDF)
•
Coleman, E. et al. (2004). Posthospital care transitions: Patterns, complications, and risk identification. Health Services
Quality Research, 39(5): 1449-1466. {click here}
Our Score
Min. score to pass
Activities include 5 – 10 items
Activities include 3 - 4 items
Activities include 2 items
X
Activities include No scoring option
Activities include 1 - 0 items
Percentage
100%
75%
50%
25%
0%
Examples/Notes:
PCMH 3E1,3,4. In-patient List (..\Practice Examples\Lakeside FP\PPC3E-1,3,4 In-pt Patient List.pdf )
PCMH 3E1-5 – (..\Practice Examples\Lakeside FP\PPC3E-1-5 Continuity of Care Policy.pdf )
PCMH 3E2,10 - (..\Practice Examples\Lakeside FP\PPC3E-2,10 Referral Policy.pdf )
PCMH 3E6,7,8 – ( ..\Practice Examples\Lakeside FP\PPC3E-6,7,8 DSME Pathway.pdf)
PCMH 3E6,7,8 – (..\Practice Examples\Lakeside FP\PPC3E-6,7,8 DXA Pathway.pdf )
PCMH 3E6,7,8 – (..\Practice Examples\Lakeside FP\PPC3E-6,7,8 H&W Pathway.pdf )
PCMH 3E7 – (..\Practice Examples\Lakeside FP\PPC3E-7 DSME Care Plan.pdf )
PCMH 3E7 – ( ..\Practice Examples\Lakeside FP\PPC3E-7 DXA Care Plan.pdf)
PCMH 3E7 – (..\Practice Examples\Lakeside FP\PPC3E-7 H&W Care Plan.pdf )
PCMH 3E7 – (..\Practice Examples\Lakeside FP\PPC3E-7_DXA_Care_Plan.pdf )
PCMH 3E9 – (..\Practice Examples\Lakeside FP\PPC3E-9 Written Transition Plan.pdf )
PCMH 3E1 – (..\Practice Examples\Elizabeth FP\3E_1_Elizabeth_Family.doc )
PCMH 3E2 – (..\Practice Examples\Elizabeth FP\3E_2_Elizabeth_Family[1].docx )
PCMH 3E2 – (..\Practice Examples\Elizabeth FP\3E_2a_ElizabethAdmissionOrders.pdf )
PCMH 3E3 – (..\Practice Examples\Elizabeth FP\3E_3_Elizabeth_Family.doc )
PCMH 3E4,5 – ( ..\Practice Examples\Elizabeth FP\3E_4and_5_Elizabeth_FamilyPostDCFollow.pdf)
PCMH 3E6 – ( ..\Practice Examples\Elizabeth FP\3E_6_Elizabeth_FamilyReferralHomeHealth.pdf)
PCMH 3E6,9 – ( ..\Practice Examples\Elizabeth FP\3E_6a_and_9_ElizabethDirueticProtocolCHF.pdf)
PCMH 3E8 – (..\Practice Examples\Elizabeth FP\3E_8_Elizabeth_FamilyAmbulatoryFU.pdf )
PCMH 3E – (..\NCQA\2011-05 (May)\PCMH3EDrugDrugInteractions.pdf )
PCMH 3E – ( ..\NCQA\2011-05 (May)\PCMH3EGenericAlternatives.pdf)
PPC 4: Patient Self- Management Support
6 Points
The practice works to improve patients' ability to self-manage health by providing educational resources and ongoing assistance and
encouragement.
36
Intent
The practice collaborates with patients and families to pursue their goals for optimal achievable health.
• Element 4A: Practice assesses patient-specific barriers to communication including language preference and hearing and vision barriers
• Element 4B: Practice documents self-management support activities in the patient record
Who will manage this standard?
NCQA’s Example Sheet:- Standard 4
PPC
4
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total
Points
A
B
X
Notes:
Element 4A: Documenting Communication Needs
2 Points
The practice assesses patient/family-specific barriers to communication using a systematic process to:
What is our current status?
What needs to happen?
Tools/ Resources
needed
Process Owner
37
Examples
Tools/
Resources
Percentage
100%
75%
50%
25%
0%
Examples/Notes:
1. Identify and display in
the record the language
preference of the patient
and family
2. Assess both hearing
and vision barriers to
communication.

Documents that show how the practice records language preference (e.g., screen shots, patient assessment forms) and how the practice
determines the percentage of its patients that prefer another language (e.g., reports from an electronic system, review of a sample of
records).

Address health literacy issues in the practice—see the National Patient Safety Foundation website “Ask Me 3”: www.npsf.org/askme3/ for
simple resources.
 Office of Health Disparities website: http://www.cdphe.state.co.us/ohd/lep.html
 NCAFP's Disparities Initiative: http://www.ncafp.com/initiatives/disparity
Min. score to pass
Our score
Practice assesses 2 items
No scoring option
Practice assesses1 item
X
No scoring option
Practice does not assess any items
PCMH4A - (click here )
NC Professional Interpreters Association: http://ncpiaonline.org/
Website for Translation Services: http://www.healthtranslations.com/
NC Services for the Deaf and Hard of Hearing with regional sign language resources available: http://www.ncdhhs.gov/dsdhh/directories.htm
Element 4B: Self-Management Support
Must Pass
4 Points
The practice conducts the following activities to support patient/family self-management, for the three important conditions:
What is our current status?
What needs to happen?
Tools/ Resources
needed
Process Owner
38
Examples
Tools/
Resources
1. Assesses patient/family
preferences, readiness to change and
self-management abilities
2. Provides educational resources in
the language or medium that the
patient/family understands
NCQA Excel
3. Provides self-monitoring tools or
Spreadsheet
personal health record, or works with
patients' self-monitoring tools or health
Please note: This is a
record, for patients/families to record
read-only example for
results in the home setting where
educational purposes.
applicable
Use your RRWB from
4. Provides or connects
NCQA Survey Tool.
patients/families to self-management
support programs
5. Provides or connects
patients/families to classes taught by
qualified instructors
6. Provides or connects
patients/families to other selfmanagement resources where needed
7. Provides written care plan to the
patient/family.
Medical record review includes:

Referrals to programs, classes or other self-management resources from the patient record

Use of tool for assessing patient preferences, readiness to change and self-management abilities

Use of educational brochures, pamphlets and video

Self-monitoring tool or personal health record
 Referrals to community resources.
NCQA Medical Record Review Worksheet For an educational PPT on the use of your RRWB ( click here)
Not all patients with important conditions require self-management support. Physicians may decide that patients already achieving good
outcomes do not require self management support; in those cases, a notation that the patient has good outcomes would suffice in place of a
record.
 American College of Physicians patient education materials and video:- http://foundation.acponline.org/hl/diabguide.htm
 Glasgow, R. et al. (2003). Implementing practical interventions to support chronic illness self-management. Joint Commission Journal on
Quality Review, 29(11), 563-574. { click here for article PDF}
 Use of PCRS tool to facilitate practice self-analysis and discussion regarding available infrastructure for incorporating self-management
support. {click here } For PDSA worksheet template (click here )
 Consider incorporating “How’s Your Health?” { PDF of How’s Your Health Book }; {click here for "How's Your Health website"}
 Patient version Self-Management Support Communication Log {click here}
 Paper and electronic versions of a PHR: { click here for an introductory article on the Personal Health Record from FPM}
 Motivational interviewing training (Merck)
 Self-Management Support Techniques & Coaching Patients for Successful Self-Management—California Healthcare Foundation; (contact
39

your coach for a copy of these DVDs)
See Health Literacy resource above in 4A.
Percentage
100%
75 – 100% of patients seen in the past 3 months have at least 3 activities documented
75%
50 – 74% of patients seen in the past 3 months have at least 3 activities documented
50%
25 – 49% of patients seen in the past 3 months have at least 3 activities documented
25%
11 – 24% of patients seen in the past 3 months have at least 3 activities documented
0%
10% or less patients seen in the past 3 months have at least 3 activities documented
Examples/Notes:
Min. score to pass
Our score
X
Written Care Plan - Pediatric – (click here )
Are You Ready? Brochure – (click here )
Adult Asthma Action Plan (click here )
Adult Asthma Self-assessment Tool – Spanish ( click here)
Adult Asthma Self-assessment Tool – English (click here )
Asthma Follow up Visit ( click here)
Diabetes Self-assessment Tool (click here )
Diabetes Medical Management Plan (click here )
Diabetes – checking blood sugar - Spanish ( click here)
Diabetes Care and Education Referral Form (click here )
Falls Prevention Checklist for the Elderly (click here )
Fitness Inventory - English (click here )
Fitness Inventory – Spanish (click here )
Tobacco Use Assessment (click here )
Mental Health/Substance Abuse Resource Guide (click here )
Hypertension SMART Goals (click here )
Group Visit Starter Kit (click here )
Group Visits for Chronically Ill Patients ( click here)
Invitation for Group Visit ( click here)
Invitation for Cardiac Group Visit (click here )
Information Gold Mine for Consumer Health Info ( click here)
For Best Information about Healthy Lifestyles (click here)
Health Center Migrant Care NC (click here )
40
PPC 5: Electronic Prescribing
8 Points
The practice employs electronic systems to order prescriptions, to check for safety and to promote efficiency when prescribing.
Intent
The practice seeks to reduce medical errors and improve efficiency by eliminating handwritten prescriptions and by using drug safety checks and cost
information when prescribing.
Who will manage this standard?
NCQA’s Example Sheet:- Standard 5
PPC
5
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total
Points
A
B
C
Notes:
41
Element 5A: Electronic Prescription Writing
3 Points
The practice uses an electronic system to write prescriptions using either:
Item
1. Electronic prescription writer—standalone system (general) with either print
capability at the office or ability to send
fax or electronic message to pharmacy
2. Electronic prescription writer that is
linked to patient-specific demographic
and clinical information.
What is our current status?
Tools/ Resources
needed
Process
Owner
Due
Date
75-100% of new prescriptions for patients seen
in the last 3 months written using this system
Practice has system capable of doing this but
does not use it
System does not have capability or less than
75% of prescriptions written using this system
75-100% of new prescriptions for patients seen
in the last 3 months written using this system
Practice has system capable of doing this but
does not use it
System does not have capability or less than
75% of prescriptions written using this system
Data
source
Tools/
Resources
Reports from system
1. E-prescribing Readiness Assessment .AAFP
2. Consumer Guide to e-prescribing
Percentage
100%
75 – 100% of new prescriptions for patients seen in the last 3 months written with Item 2
75%
75 – 100% of new prescriptions for patients seen in the last 3 months written with Item 1
50%
No scoring option
25%
Practice has system capable of either Item 1 or Item 2, but does not use it
0%
System does not have capability or less than 75% of prescriptions written using this system
Examples/Notes:
Min. score to pass
Our score
X
PCMH 5A – (..\Practice Examples\Elizabeth FP\5A_Elizabeth_FP_e-prescribing.xlsx )
EHR Process from TransforMED ( click here)
42
Element 5B: Prescribing Decision Support—Safety
3 Points
Clinicians in the practice write prescriptions using electronic prescription reference information at the point of care, including the following types of
alerts and information:
What is our current status?
Tools/ Resources
Process Owner
What needs to happen?
needed
1. Drug-drug interactions based on general
Yes
No
information
2. Drug-drug interactions specific to drugs the patient
Yes
No
takes
3. Drug-disease interactions based on general
Yes
No
information
4. Drug-disease interactions specific to diseases the
Yes
No
patient has
5. Drug-allergy alerts based on general information
Yes
No
6. Drug-allergy alerts specific to the patient
Yes
No
7. Drug-patient history alerts based on general
Yes
No
information
8. Appropriate dosing based on general information
Yes
No
9. Appropriate dosing calculated for the patient
Yes
No
10. Therapeutic monitoring associated with specific
Yes
No
drug utilization based on general information (drug-lab
alerts)
11. Duplication of drugs in a therapeutic class based
Yes
No
on general information
12. Duplication of drugs in a therapeutic class specific
Yes
No
to the patient
13. Drugs to be avoided in the elderly based on
Yes
No
general information
14. Drugs to be avoided in the elderly based on age of
Yes
No
the patient
15. Patient appropriate medication
Yes
No
Examples
Percentage
100%
75%
50%
25%
0%
Reports from the system, paper or electronic showing an example of use of each item.
Practice uses 8 or more kinds of alerts and information
Practice uses 4 – 7 kinds of alerts and information
Practice uses 2 – 3 or more kinds of alerts and information
System has capability of providing 6 or more kinds of alerts, but practice does not use them
No system capability, system has capability for fewer than 6 kinds of alerts or practice uses
fewer than 2 kinds of alerts and information
Examples/Notes:
PCMH 5B – (click here )
Min. score to pass
Our score
X
43
PCMH 5B – ( click here)
20 Tips to Prevent Medication Errors ( click here)
Drugs to be Avoided in the Elderly (click here )
Appropriate Dosing of Tylenol in Children (click here )
Understanding the Risks of OTC meds (click here )
Refill Protocol (click here )
44
Element 5C: Prescribing Decision Support—Efficiency
2 Points
Clinicians engage in cost-efficient prescribing through one or more of the following tools
What is our current status?
1. Electronic prescription writer with
general automatic alerts for different
choices including generics
Tools/ Resources
needed
Process Owner
We use this tool
System has capability to support both options;
practice does not use it
System does not have capability or practice does
not use either tool
2. Electronic prescription writer
connected to payer-specific formulary
that automatically alerts clinician to
alternative drugs, including generics.
We use this tool
System has capability to support both options;
practice does not use it
System does not have capability or practice does
not use either tool
Data source
Reports from the system, screen shots, practice protocols.
Tools/
Resources
PCMH5C – Generic Alternatives ( click here)
Percentage
100%
75%
50%
25%
0%
Notes:
Min. score to pass
Practice uses 2 tools
Practice uses 1 tool
No scoring option
System has capability to support both options; but does not use it
System does not have capability or practice does not use either tool
Our Score
X
45
PPC 6: Test Tracking
13 Points
The practice systematically tracks tests ordered and test results, and systematically follows up with patients.
Intent
The practice works to improve effectiveness of care, patient safety and efficiency by using timely information on all tests and results.
Who will manage this standard?
NCQA’s Example Sheet:- Standard 6
PPC
6
A
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total
Points
x
B
Notes:
46
Element 6A: Test Tracking and Follow-up
Must Pass
7 Points
The practice systematically tracks tests and follows up in the following manner:
What is our current status?
What needs to happen?
Tools/ Resources needed
Due
Date
Process
Owner
Data source
1. Tracks all laboratory tests ordered or done within
the practice, until results are available to the
clinician, flagging overdue results
2. Tracks all imaging tests ordered or done within
the practice, until results are available to the
clinician, flagging overdue results
3. Flags abnormal test results, bringing them to a
clinician’s attention
4. Follows up with patients/families for all abnormal
test results
5. Follows-up with inpatient facility on hearing
screening and metabolic screening to get results
6. Notifies patients/families of all normal test
results.
Reports
Examples
Reports or logs—may be a paper log or an electronic in-box showing outstanding tests and showing how the practice flags abnormal results.
Tools/
Resources
Percentage
100%
75%
50%
25%
0%
1. Excel workbook for test, newborn screening results and referral tracking
2. Paper test tracking log {click here}
3. American College of Medical Genetics ACTsheets (click here )
Min. score to pass
Practice does 4 – 6 types of tracking and follow-up
No scoring option
Practice does 3 types of tracking and follow-up
Practice’s electronic system has the capability to all 4 types of tracking and follow-up but
practice does not use it
Practice’s system does not have capability to track, or the practice does fewer than 3 types
of tracking and follow-up
Our score
X
Examples/Notes:
PCMH 6A1,3,4,6 – (..\Practice Examples\Lakeside FP\PPC6A-1,3,4,6 LO Labs.pdf )
PCMH 6A1,3,4,6 – (..\Practice Examples\Lakeside FP\PPC6A-1,3,4,6 LO Labs.pdf )
PCMH 6A1 – ( ..\Practice Examples\Elizabeth FP\6A_1_Elizabeth_FamilyLabOrderForm.pdf)
PCMH 6A2 – (..\Practice Examples\Elizabeth FP\6A_2_ElizabethReferrals.pdf )
PCMH 6A3 – (..\Practice Examples\Elizabeth FP\6A_3a_Elizabeth_FamilyAbnormalReport.pdf )
PCMH 6A4 – ( ..\Practice Examples\Elizabeth FP\6A_4_Elizabeth_FamilyAbnormalLab.pdf)
PCMH 6A6 – (..\Practice Examples\Elizabeth FP\6A_6_Elizabeth_FamilyNormalLab.pdf )
47
PCMH 6A – (..\NCQA\2011-05 (May)\PCMH6AClincalMeasuresChronicCondition.pdf )
Element 6B: Electronic System for Managing Tests
6 Points
The practice uses an electronic system to::
What is our current status?
What needs to happen?
Tools/ Resources
needed
Process
Owner
Due
Date
1. Order lab tests
Data source
2. Order imaging tests
3. Retrieve lab results directly from
source
4. Retrieve imaging text reports
directly from source
5. Retrieve images directly from the
source
6. Route and manage current and
historical test results to appropriate
clinical personnel for review, filtering
and comparison
7. Flag duplicate tests ordered
8. Generate alerts for appropriateness
of tests ordered.
Reports
Examples
Data source: Reports or screen shots from the system showing examples of each of the functions.
Tools/
Resources
Percentage
100%
75%
50%
25%
0%

See NCQA’s example slides
Min. score to pass
Practice uses 5 – 8 functions
Practice uses 3 – 4 functions
Practice uses 1 – 2 functions
No scoring option
Practice does not use system
Our Score
X
48
Examples/Notes:
PCMH 6B1,3,7 – (..\Practice Examples\Lakeside FP\PPC6B 1,3,7 Electronic Lab Test Mgmt LO.pdf )
PCMH 6B – ( ..\NCQA\2011-05 (May)\TestTrackingLogEx.pdf)
PCMH 6B – (..\NCQA\2011-05 (May)\ElectronicTestTracking.pdf )
PCMH 6B – (..\NCQA\2011-05 (May)\LabImagingOrderScreenshot.pdf )
PCMH 6B – (..\NCQA\2011-05 (May)\NotifyPtAbnormalResults.pdf )
49
PPC 7: Referral Tracking
4 Points
The practice systematically documents and tracks referrals and referral results.
Intent
The practice seeks to improve effectiveness, timeliness and coordination of care by following through on consultations with other practitioners.
Element 7A:
1. Do we currently provide all of the necessary information about our patients to people we consult with? Such as reasons for the consult/ referral, dx, social
and family history, pertinent clinical finding, insurance information, etc?
2. Do we get the consult back from the specialist or consultant?
Who will manage this standard?
NCQA’s Example Sheet:- Standard 7
PPC
7
Must
Pass
Actions for Point
Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total Points
A
Notes:
Element 7A: Referral Tracking
Must Pass
4 Points
Outside of paper medical records and patient visits, the practice uses a paper-based or electronic system to assist in tracking practitioner referrals
designated as critical until the specialist or consultant report returns to the practice. The practice uses a system that includes the following information
for its referrals:
What is our current status?
1. Origination
2. Clinical details
Referring provider
Contact information
Reason
Pertinent clinical findings
What needs to happen?
Tools/ Resources needed
Process
Owner
Due Date
Referral form
Referral form
50
Support person
Functional status
Family history
Social history
Plan of care
Health care providers
3. Tracking status
4. Administrative
details.
Referral tracking
worksheet
Insurance information
information about whether the
plan needs approval for services
the consultant or specialist will be
providing
Referral form
Data source
Examples
Written logs or other paper-based documents if not electronic, reports from the system if electronic.
Tools/
Resources
Referral form
Audit Paper log or Electronic log
Schuldermann, P. (2004). Improving patient care: Using a tracking book for unresolved issues. Family Practice Management, 11(4),
56, 59. Includes tool PDF. { click here }
Murray, M (2002). Reducing Waits and Delays in the referral process. Family Practice Management 39-42 (click here )
Co-Management Agreement with Specialist (click here )
Min. score to pass
Our Score
Practice uses system that includes all 4 items
Practice uses system that includes 2 – 3 items
Practice uses system that includes 1 item
X
No scoring option
System does not include any of the items
Percentage
100%
75%
50%
25%
0%
Examples/Notes:
PCMH 7A1-4 – ( ..\Practice Examples\Lakeside FP\PPC7A-1-4 Referral Policy.pdf)
PCMH 7A1-4 – ( ..\Practice Examples\Lakeside FP\PPC7A-1-4-Referral Tracking.pdf)
PCMH 7A – ( ..\NCQA\2011-05 (May)\ReferralTrackingEx.pdf)
PCMH 7A - (..\NCQA\2011-05 (May)\ReferralTrackingLogEx.pdf )
A Sample Tracking Book (click here )
51
PPC 8: Performance Reporting and Improvement
15 Points
The practice regularly measures its performance and takes actions to continuously improve.
Intent
The practice seeks to improve effectiveness, efficiency, timeliness and other aspects of quality by measuring and reporting performance, comparing
itself to national benchmarks, giving physicians regular feedback and taking actions to improve.
Who will manage this standard?
NCQA’s Example Sheet:- Standard 8
PPC
8
A
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total
Points
X
B
C
X
D
E
F
Notes:
52
Element 8A: Measures of Performance
Must Pass
3 Points
The practice measures or receives data on the following types of performance by physician or across the practice:
What needs to happen?
Resources needed
Process
Owner
Due
Date
1. Clinical process (e.g., percentage of women 50+ with
mammograms or childhood vaccination rates)
2. Clinical outcomes (e.g., HbA1c levels for diabetics)
3. Service data (e.g., backlogs or wait times)
Data source
Examples
4. Patient safety issues (e.g., medication errors).
Reports
Manual review of a sample of patient records, patient surveys, practice management system, registry, health plan-provided data, medical group
provided data, electronic database.
1. Practice gets credit for Item 1 and 2 if they have current NCQA recognition for Diabetes or Heart Stroke
2. Registry
a. Reach My Doctor Reports
b. CINA Reports. Information at http://www.cina-us.com/pqrifaq.html
c. NCIR (NC Immunization Registry) Reports at http://www.immunizenc.com/ncir.htm
3. Custom electronic reports—Query, Crystal, etc.
4. Reporting available through EMR
Tools/
Resources
Percentage
100%
75%
50%
25%
0%
Examples/Notes:
5. MGMA’s Physician Practice Patient Safety Assessment Tool {weblink to interactive self-assessment tool}
6. Medication Safety
a. Ghandi, T et al. (2003). Adverse drug effects in ambulatory care. NEJM . 348:1556-1564.
b. “What Medications Does Your Patient Take: Enhancing Medication Safety in the Outpatient Setting.” IHI website. {click here }
c. Examples of outpatient medication reconciliation lists
i. The Med List on Massachusett’s Coalition for Prevention of Medical Errors website {link to Coalition website for resources}
ii. Other patient medication reconciliation lists {example medication list PDF} {second example medication list PDF } {third
example medication list PDF}
7. Measurement Patient Safety
a. Background IHI Outpatient Adverse Effect Trigger Tool and Toolkit {(click here)}
Min. score to pass
Our Score
Practice measures at least 2 types of performance
No scoring option
Practice measures 1 type of performance
X
No scoring option
No areas of performance measured
PCMH 8A,C,D,E,F – ( ..\Practice Examples\Lakeside FP\PPC8A,C,D,E,F NCQA Clinical Outcome Data.pdf)
PCMH 8A,C,D,E,F - (..\Practice Examples\Lakeside FP\PPC8A,C,D,E,F NCQA Slide.pdf )
PCMH 8A1,2 – (..\Practice Examples\Lakeside FP\PPC8A-1-2 NCQA Clinical Outcome Data.pdf )
PCMH 8A3 – (..\Practice Examples\Lakeside FP\PPC8A-3 Service Data.pdf )
PCMH 8A4 – (..\Practice Examples\Lakeside FP\PPC8A-4 Journey Report.pdf )
53
PCMH 8A3 – Patient Cycle Tool (click here ) Then would need to put the data into a workbook/spreadsheet (click here )
54
Element 8B: Patient Experience Data
3 Points
The practice collects data on patient experience with care in the following areas:
What is our current status?
Data
source
What needs to happen?
Tools/ Resources
needed
Process
Owner
Due
Date
1. Patient access to care
2. Quality of physician communication
3. Patient/family confidence in self care
4. Patient/family satisfaction with care.
Reports; may use a phone, paper or electronic survey
Practice may qualify for 50% of points if able to demonstrate that a patient advocacy group or board that meets periodically has been
established. The gathering of patient feedback in this context must be documented in order to be eligible.
Tools/
Resources
Percentage
100%
75%
50%
25%
0%
Examples/Notes:
1. Reports
a. Press Ganey Reports
b. CAHPS Reports. From https://www.cahps.ahrq.gov/content/products/CG/PROD_CG_CG40Products.asp
2. Patient Satisfaction Survey
a. Patient Feedback Card (click here) & Excel Tracking Sheet (click here) Patient Survey 2 (click here )
3. Patient Advocacy Board
a. Institute of Family-Centered Care. (2007). Selecting, Preparing and Supporting Patient and Family Advisors in Primary Care.
www.familycenteredcare.org
4. Related articles
a. Luallin, M. (2004). Implementing patient satisfaction survey findings into a customer service action plan. Medical Practice
Management, 90-94. { PDF }
Min. score to pass
Our Score
Practice collects data on 3 – 4 areas
No scoring option
Practice collects data on 1 – 2 areas
X
No scoring option
Practice do not collect data in any areas
PCMH 8B1-4 – (..\Practice Examples\Lakeside FP\PPC8B-1-4 Patient Experience Data by Practice.pdf )
PCMH 8B1-4 – (..\Practice Examples\Lakeside FP\PPC8B-1-4 Patient Experience Data by Provider.pdf )
Family Post Visit Survey (click here)
Communication Skills – Breaking Bad News (click here)
Latino Focus Group Questions (click here)
Family/Caregiver Survey (click here)
Measuring Medical Homes PDF – full of surveys/tools for Peds and FM ( click here)
EQUIPP - Education in Quality Improvement for Pediatric Practice (click here )
55
Element 8C: Reporting to Physicians
Must Pass
3 Points
The practice reports on performance on the measures in 8A and 8B:
What is our current status?
What needs to happen?
Tools/ Resources
needed
Process Owner
Data source
1. Across the practice
2. By individual physician.
Reports
Examples
Blinded reports showing summary practice performance or individual physician performance; blinded letters to physicians showing performance.
Addnl.
information
Tools/
Resources






Percentage
100%
75%
50%
25%
0%
Examples/Notes:
NCQA worksheet
Reports may come from within or outside of the practice—must reflect entire population and not just a subgroup covered by a single payer
Practice to demonstrate how report results are communicated to the whole practice as well as to individual providers
RMD Registry reports
EMR Registry reports
Customized electronic reports—Crystal, Query, etc.
Excel workbooks with audit results
Min. score to pass
Our score
Practice reports to physicians results both results both across the practice and by
physicians
No scoring option
Practice reports to physicians results either across the practice or by physicians
X
No scoring option
No areas of performance reported to physicians
PCMH 8C1 - (..\NCQA\2011-05 (May)\PCMH6EReportingAcrossPractice.pdf)
PCMH 8C2 – (..\NCQA\2011-05 (May)\PCMH6EResultsbyClinician.pdf )
PCMH 8C2 – (..\Practice Examples\Lakeside FP\PPC8C-2 Adult Medical Record and Survey Workbook2.pdf )
PCMH 8C2 – ( ..\Practice Examples\Lakeside FP\PPC8C-2 Service Data Individual MD.pdf)
Diabetes Registry ( click here)
CSHCN Registry (click here )
56
Element 8D: Setting Goals and Taking Action
3 Points
The practice uses performance data to:
What is our current status?
What needs to happen?
Tools/ Resources
needed
Process Owner
1. Set goals based on measurement
NCQA worksheet
Please note: This is a
results referenced in Elements 8A
and 8B.
read-only example for
educational purposes.
2. Take action where identified to
Use your RRWB from
improve performance of individual
NCQA Survey Tool.
physicians or of the practice as a
whole.
Data source Reports
Examples
Reports or completion of the PPC-PCMH Quality Measurement and Improvement worksheet.
Tools/
1. Consider incorporating use of meeting minutes and/or PDSA Worksheets
Resources
2. Example templates: {Meeting Agenda template}{Meeting Minutes template}{PDSA worksheet}
3. Example templates for setting goals and aim statement : (click here)
4. Article: Schwarz, M. et al. (1999). A team approach to quality improvement. FPM. 6(4):25-30. { article}
5. For an educational PPT on the use of your RRWB ( click here)
Percentage
Min. score to pass
Our score
100%
Practice does 2 items
75%
No scoring option
50%
Practice does 1 item
X
25%
No scoring option
0%
Practice does no items
Examples/Notes:
Setting Goals and Taking Actions (..\NCQA\2011-06 (Jun)\PPC8D0001.pdf )
57
Element 8E: Reporting Standardized Measures
2 Points
The practice produces reports on its performance using nationally approved clinical performance measures.
What is our current status?
Data
source
Examples
Tools/
Resources
What needs to happen?
Tools/ Resources
needed
Process Owner
How many national measures do you
produce as a practice?
Reports
Reports showing performance measures calculated by practice.
1. See the PCMH Measures Directory for reportable measures associated with DM, CAD, Prevention, Depression, and Low Back Pain
2. National Voluntary Consensus Standards for Ambulatory Care endorsed by NQF:
http://www.qualityforum.org/projects/ongoing/ambulatory/index.asp.
Percentage
100%
Practice produces reports using 10 or more nationally approved performance measures
75%
Practice produces reports using 5 - 9 nationally approved performance measures
50%
Practice produces reports using 3 - 4 nationally approved performance measures
25%
No scoring option
0%
Practice produces reports using 0 - 2 nationally approved performance measures
Examples/Notes:
Min. score to pass
Our score
X
Example of Satisfaction Survey across a practice ( ..\Practice Examples\Lakeside FP\PPC8E-1 Service Data by Practice.pdf)
Practice Level Diabetes Data (..\NCQA\2011-06 (Jun)\PCC8E0001.pdf )
You can go to the above website (National Voluntary Consensus Standards for Ambulatory Care endorsed by NQF) and see some of the national
standards for Ambulatory Care and Immunizations.
58
Element 8F: Electronic Reporting—External Entities
1 Point
The practice electronically reports results on nationally approved measures to the public sector, health plans or others.
What is our current status?
Do you currently participate in report
clinical measures to outside
organizations?
Reports
Data source
Examples
Tools/ Resources
Yes
What needs to happen?
75%
50%
25%
0%
Examples/Notes:
Process Owner
No
Report to payer or other user from practice’s electronic system.
Percentage
100%
Tools/ Resources
needed
Min. score to
pass
Practice transmits 10 or more nationally approved performance measures to an external
entity
Practice transmits 5 - 9 nationally approved performance measures to an external entity
Practice transmits 3 – 4 nationally approved performance measures to an external entity
Practice transmits 1 – 2 nationally approved performance measures to an external entity
Practice does not transmit any measures
Our score
X
Reporting results on nationally approved measures to the public sector ( click here)
PCMH 8F - ( ..\Practice Examples\Lakeside FP\PPC8F Electronic Reporting-External Entities.pdf)
59
PPC 9: Advanced Electronic Communications
4 Points
The practice systematically manages patient information and uses the information for population management to support patient care.
Intent
The practice maximizes use of electronic communication to improve timeliness, effectiveness, efficiency and coordination of care.
Who will manage this standard?
NCQA’s Example Sheet:- Standard 9
PPC
9
Must
Pass
Actions for Point Person
Staff responsible
Ready
for
NCQA
The person
assigned to do
the final review
Standard
Complete
NCQA
document
linked
Points
Completed
Points
Pending
Upload
completed
Total
Points
A
B
C
Notes:
60
Element 9A: Availability of Interactive Web Site
4 Points
The practice provides patients/families with access to an interactive Web site that allows them to:
Does your practice have a website that allows patients to:
Examples
Tools/ Resources needed
1. Request appointments by reviewing
clinicians schedules
Yes
No


Website with HIPPA complaint communication function
Reach My Doctor – “Basic Patient Communication” function
2. Request referrals
Yes
No


Website with HIPPA complaint communication function
Reach My Doctor – “Basic Patient Communication” function
3. Request test results
Yes
No


Website with HIPPA complaint communication function
Reach My Doctor – “Basic Patient Communication” function
4. Request prescription refills
Yes
No


Website with HIPPA complaint communication function
Reach My Doctor – “Basic Patient Communication” function
5. See elements of their medical record
Yes
No


Website with HIPPA complaint communication function
Reach My Doctor – “Basic Patient Communication” function
6. Import elements of their medical record into
a personal health record.
Yes
No


Website with HIPPA complaint communication function
Reach My Doctor – “Basic Patient Communication” function
Process
Owner
Due Date
Screen shots showing presence of web-based functionality
Tools/
If your practice doesn’t have this functionality, sign up for ReachMyDoctor Basic Patient Communication by contacting clicking here .
Resource
Percentage
Min. score to pass
Our Score
100%
Practice providers 5 – 6 items
75%
Practice providers 3 – 4 items
50%
Practice providers 1 – 2 items
X
25%
No scoring option
0%
Practice does not any items
Examples/Notes:
PCMH 9A1 - (..\Practice Examples\Elizabeth FP\9A_1_Elizabeth.doc )
PCMH 9A4 – (..\Practice Examples\Elizabeth FP\9A_4_Elizabeth.doc )
Practice Brochure (click here )
Element 9B: Electronic Patient Identification
2 Points
61
The practice combines use of electronic information and clinical decision-support to contact the following types of patients, once identified, by e-mail:
What is our current status?
1. Patients needing clinical review
or action
Examples
Tools/
Resources
Percentage
100%
75%
50%
25%
0%
Notes:
Tools/ Resources needed
Process
Owner
Due
Date


Website with HIPPA complaint communication function
Reach My Doctor – “Premium Patient Communication”
function
2. Patients on a particular
 Website with HIPPA complaint communication function
Yes
medication
 Reach My Doctor – “Premium Patient Communication”
No
function
3. Patients needing preventive
 Website with HIPPA complaint communication function
Yes
care
 Reach My Doctor – “Premium Patient Communication”
No
function
4. Patients needing specific tests
 Website with HIPPA complaint communication function
Yes
 Reach My Doctor – “Premium Patient Communication”
No
function
 CareSpace
5. Patients needing follow up visits
 Website with HIPPA complaint communication function
Yes
 Reach My Doctor – “Premium Patient Communication”
No
function
 CareSpace
6. Patients who might benefit from
 Website with HIPPA complaint communication function
disease or case management
Yes
 Reach My Doctor – “Premium Patient Communication”
support.
No
function.
 CareNotes and CareTeams
Screen shots showing identification of patients for the above items and an example of e-mail communication with patients based on electronic
identification.
If your practice doesn’t have this functionality, sign up for ReachMyDoctor Premium Patient Communication by click here . The practice can add
a subscription fee to this service.
Min. score to pass
Our Score
Practice uses electronic information and communication for 5 – 6 items
Practice uses electronic information and communication for 3 - 4 items
Practice uses electronic information and communication for 1 - 2 items
X
No scoring option
Practice does not use electronic information for any items
Yes
No
62
Element 9C: Electronic Care Management Support
1 Point
For patients with the three clinically important conditions, the practice care management team uses electronic communication for the following:
What is our current status?
Examples
Process
Owner
Tools/ Resources needed
1. To communicate with disease or case
managers about patient needs


2. Web-based educational modules for patient
self-management.




Due
Date
Website with HIPPA complaint communication function
Reach My Doctor – “Premium Patient Communication”
function.
CareNotes and CareTeams
www.howsyourhealth.com
www.mayoclinic.com
http://www.newhealthpartnerships.org/PatientsPuzzlePiec
ePrint.aspx?id=40&linkidentifier=id&itemid=40
Screen shots showing electronic communication about care management. Screen shots or links to education modules.
Tools/
Resources
Percentage
Min. score to pass
100%
Practice uses electronic communication for 2 items
75%
Practice uses electronic communication for 1 items
50%
No scoring option
25%
No scoring option
Our point
X
0%
Practice does not use electronic communication for any items
Examples/Notes:
Partnering in Self-management Support – a Toolkit for Clinicians: ( click here) Tremendous Resource from IHI with numerous links to multiple
resources for self-management
63