NCQA PCMH 2014
MUST-PASS ELEMENTS
Essentials
§ 
§ 
§ 
§ 
§ 
§ 
Defining the Must-Pass Elements
Understanding scoring
Why the Must-Pass Elements are critical
Tips to optimize scores on Must-Pass Elements
Meaningful Use Criteria for Must-Pass Elements
How the Elements have and will continue to evolve
2
Six Standards in PCMH 2014
1A
2D
3D
4B
PatientCentered
Access
Team-Based
Care
Population
Health
Management
Care
Management
and Support
Continuity
Patient
Information
Identify Patients
for Care
Management
Clinical Data
Care Planning
and Self-Care
Support
Patient-Centered
Appointment
Access
Medical Home
Responsibilities
24/7 Access to
Clinical Advice
Electronic
Access
Culturally and
Linguistically
Appropriate
Services (CLAS)
The Practice
Team
Comprehensive
Health
Assessment
Medication
Management
Use Data for
Population
Management
Use Electronic
Prescribing
Implement
Evidence-Based
Decision Support
NOTE: Red boxes indicate Must-Pass Elements.
Support SelfCare and Shared
Decision Making
5B
Care
Coordination
and Care
Transitions
6D
Performance
Measurement
and Quality
Improvement
Measure Clinical Quality
Performance
Test Tracking
and Follow-Up
Measure Resource Use
and Care Coordination
Measure Patient and
Family Experience
Referral
Tracking and
Follow-Up
Implement Continuous
Quality Improvement
Demonstrate Continuous
Quality Improvement
Coordinate Care
Transitions
Report Performance
Use Certified EHR
Technology
3
The Must-Pass Elements
What is the structure of PCMH 2014?
§  Six standards
§  Six Must-Pass Elements
§  At least a 50% score on each
§  100 total points
Three levels of Recognition:
§  Level 1: 35-59 points (6 Must-Pass Elements)
§  Level 2: 60-84 points (6 Must-Pass Elements)
§  Level 3: 85-100 points (6 Must-Pass Elements)
Six Must-Pass Elements are considered essential to the Patient-Centered Medical Home
and are required for practices at all recognition levels. Practices must achieve a score of
50% or higher on Must-Pass Elements.
4
2014 NCQA Must-Pass Elements
§  Element 1A – Patient-Centered Appointment Access
§  Element 2D – The Practice Team
§  Element 3D – Use Data for Population Management
§  Element 4B – Care Planning and Self-Care Support
§  Element 5B – Referral Tracking and Follow-Up
§  Element 6D – Implement Continuous Quality Improvement
5
Points for the 2014 NCQA
Must-Pass Elements
§  1A – Patient-Centered Appointment Access 4.5 points
§  2D – The Practice Team 4 points
§  3D – Use Data for Population Management 5 points
§  4B – Care Planning and Self-Care Support 4 points
§  5B – Referral Tracking and Follow-Up 6 points
§  6D – Implement Continuous Quality Improvement 4 points
Total points = 27.5 (100%)
50% Score = 13.75 points
6
2011–2014 Evolution
PCMH 2011
§  Explicitly incorporated health information technology meaningful use criteria
§  Added content and examples for pediatric practices on parental decision
making, age-appropriate immunizations, teen privacy and other issues
§  Added voluntary distinction for practices that participate in the CAHPS
PCMH survey of patient experience and submit data to NCQA
§  Added content and examples for behavioral healthcare
PCMH 2014
§ 
§ 
§ 
§ 
§ 
More integration of behavioral healthcare
Additional emphasis on team-based care
Focus care management for high-need populations
Involvement of patients and families in QI activities
Alignment of QI activities with the Triple Aim: improved quality, cost and
experience of care
§  Alignment with health information technology Meaningful Use Stage 2
7
Rationale for Must-Pass Elements
§  Identifies critical concepts of PCMH
§  Helps focus Level 1 practices on the most important
aspects of PCMH
§  Guides practices through PCMH evolution and
continuous quality improvement
§  Standardizes “Recognition”
8
Documentation Types
1.  Documented Process: Written procedures, protocols,
processes for staff, workflow forms (not explanations);
must include practice name and date of implementation
2.  Reports: Aggregated data showing evidence
3.  Records or Files: Patient files or registry entries
documenting action taken; data from medical records
for care management
4.  Materials: Information for patients or clinicians, e.g.,
clinical guidelines, self-management, and educational
resources
NOTE: Screen shots or electronic “copies” may be used as examples (EHR
capability), materials (website resources), reports (logs), or records (advice
documentation).
9
PCMH 1A: Patient-Centered Access
1A. Patient-Centered Appointment Access Must Pass – 4.5 Points
The practice has a written process and defined standards for providing access
to appointments and regularly assesses its performance on:
F1. Providing routine and urgent same-day appointments CRITICAL FACTOR
F2. Providing routine and urgent-care appointments outside regular business
hours
F3. Providing alternative types of clinical encounters
F4. Availability of appointments
F5. Monitoring no-show rates
F6. Acting on identified opportunities to improve access
NOTE: Critical Factors in a Must-Pass Element are essential for Recognition.
10
PCMH 1A: Scoring
MUST PASS – 4.5 Points
Scoring
§ 5-6 Factors (including Factor 1) = 100%
§ 3-4 Factors (including Factor 1) = 75%
§ 2 Factors (including Factor 1) = 50% MUST-PASS THRESHOLD
§ 1 Factor (including Factor 1) = 25%
§ 0 Factors = 0%
Must meet at least 2 Factors (including Factor 1) to pass this Must-Pass Element
and receive any level of Recognition.
11
PCMH 1A: Documentation
F1-6: Documented process, definition of appointment types, and reports.
F1. Report(s) with at least 5 days of data showing availability/use of same-day
appointments for both routine and urgent care
F2. Materials communicating extended hours or report showing after-hours
availability (process to arrange after-hours access not required if practice
has regular extended hours)
F3. Report with frequency of scheduled alternative encounter types in recent
30-calendar-day period
F4. Report showing appointment wait-times compared to practice-defined
standards, including policy for how practice monitors appointment
availability, with at least 5 days of data
F5. Report showing rate of no-shows from a recent 30-calendar-day period
(patients seen/scheduled visits)
F6. Documented process indicating the method a practice uses to select,
analyze and update its approach to create greater access to
appointments and a report showing practice has evaluated access data
and implemented QI Plan to create greater access
12
PCMH 1A: Routine & Urgent Care
Outside Regular Hours
From Practice Brochure:
Accessible Services:
§  We have regular extended hours beyond the normal 9:00 a.m. - 5:00 p.m.
§  We have a physician on call for emergencies after-hours
§  We strive to achieve excellent communication
Source: www.ncqa.org
13
Documentation Examples
Source: www.ncqa.org
14
PCMH 2D: The Practice Team
2D. The Practice Team Must Pass – 4 Points
The practice uses a team to provide a range of patient care services by:
F1.
F2.
F3.
Defining roles for clinical and non-clinical team members
Identifying the team structure and the staff who lead and sustain team-based care
Holding scheduled patient-care team meetings or a structured communication
process focused on individual patient care CRITICAL FACTOR
F4. Using standing orders for services
F5. Training and assigning members of the care team to coordinate care for individual
patients
F6. Training and assigning members of the care team to support patients, families, and
caregivers in self-management, self-efficacy, and behavior change
F7. Training and assigning members of the care team to manage the patient population
F8. Holding scheduled team meetings to address practice functioning
F9. Involving care team staff in the practice’s performance evaluation and quality
improvement activities
F10. Involving patients/families/caregivers in quality improvement activities or on the
practice’s advisory council
NOTE: Critical Factors in a Must-Pass Element are essential for Recognition.
15
PCMH 2D: Scoring
MUST PASS – 4 Points
Scoring
§  10 Factors = 100%
§  8-9 Factors = 75%
§  5-7 Factors = 50% MUST-PASS THRESHOLD
§  2-4 Factors = 25%
§  0-1 Factors = 0%
Must meet at least 5-7 Factors (including Factor 3) to pass this Must-Pass Element
and receive any level of Recognition.
16
PCMH 2D: Documentation
F1-10: Requirements
F1, 2, 4-7. Staff position descriptions or responsibilities
F3. Description of staff communication processes and sample of how
pre-visit planning is conducted
F4. Written standing orders
F5-7. Description of training process, schedule, materials
F6. Description of staff communication process and examples of
training materials
F8. Description of staff communication processes and sample
F9. Description of staff role in practice improvement process or
minutes demonstrating staff involvement
F10. Process demonstrating how it involves patients/families in QI
teams or advisory council
17
PCMH 3D: Use Data for
Population Management
3D. Use Data for Population Management Must Pass – 5 Points
At least annually, the practice proactively identifies populations of
patients and reminds them, or their families/caregivers, of needed care
based on patient information, clinical data, health assessments, and
evidenced-based guidelines, including:
F1. At least two different preventive care services +
F2. At least two different immunizations +
F3. At least three different chronic or acute care services +
F4. Patients not recently seen by the practice
F5. Medication monitoring or alerts
+ Stage 2 Core Meaningful Use Requirement
18
PCMH 3D: Scoring
MUST PASS – 5 Points
Scoring
§  4-5 Factors = 100%
§  3 Factors = 75%
§  2 Factors = 50% MUST-PASS THRESHOLD
§  1 Factor = 25%
§  0 Factors = 0%
Must meet at least 2 Factors to pass this Must-Pass Element and receive any level
of Recognition.
19
PCMH 3D: Documentation
F1-5: Requirements
Reports or Lists of patients needing services generated within
the past 12 months (health plan data okay if 75% of patient
population).
AND
Materials showing how patients were notified for each service
(e.g., template letter, phone call script, screen shot of e-notice).
The practice must perform these functions at least annually.
20
PCMH 4B: Care Planning
and Self-Care Support
4B. Care Planning and Self-Care Support Must Pass – 4 Points
Care team and patient/family/caregiver collaborate (at relevant visits) to
develop and update an individual care plan that includes the following
features for at least 75 percent of the patients identified in 4A.
F1. Incorporates patient preferences and functional/ lifestyle goals
F2. Identifies treatment goals
F3. Assesses and addresses potential barriers to meeting goals
F4. Includes a self-management plan
F5. Is provided in writing to patient/family/caregiver
21
PCMH 4B: Scoring
MUST PASS – 4 Points
Scoring
§ 5 Factors = 100%
§ 4 Factors = 75%
§ 3 Factors = 50% MUST-PASS THRESHOLD
§ 1-2 Factors = 25%
§ 0 Factors = 0%
Must meet at least 3 Factors to pass this Must-Pass Element and receive any level
of Recognition.
22
PCMH 4B: Documentation
F1-5: Requirements
Report from electronic system OR submission of Record
Review Workbook (RRWB).
AND
Examples of how each factor is met.
23
PCMH 4B: Care Plan Example
Source: www.ncqa.org
24
Documentation from Patient Records
PCMH Elements 4B and 4C (Medication Management)
§ Require medical record abstraction of data
§ Need percentage of patients for each factor based on
numerator and denominator
Two methods to collect and submit patient data
§ Method #1 – Report from the electronic system
§ Method #2 – Record Review Workbook (RRWB)
§  Excel workbook in the Survey Tool
§  Tool to identify sample of patients and abstract data needed for
Elements 4B and 4C
25
RRWB: Overview of Steps for Method 2
1.  Locate RRWB file in Survey Tool
2.  Download and save file to computer
3.  Review RRWB instructions (Tab 1) and data needed from patient
records
4.  Select patient records to review
5.  Review patient records for data
6.  Enter data in RRWB (Tab 2)
7.  Enter Yes/No responses from RRWB in Survey Tool for Elements
4B and 4C
8.  Attach RRWB to Survey Tool and link to Elements 4B and 4C
26
RRWB: Look at Instructions
Click here
27
Record Review Workbook
28
PCMH 5B: Referral Tracking
and Follow-Up
5B. Referral Tracking & Follow-Up Must Pass – 6 Points
The practice:
F1. Considers available performance information on consultants/
specialists for referral recommendations
F2. Maintains formal and informal agreements with a subset of
specialists based on established criteria
F3. Maintains agreements with behavioral healthcare providers
F4. Integrates behavioral healthcare providers within the practice site
F5. Gives the consultant/specialist the clinical question, required timing
and type of referral
29
PCMH 5B: Referral Tracking
and Follow-Up (cont.)
F6. Gives the consultant/specialist pertinent demographic and clinical
data, including test results and current care plan
F7. Has capacity for electronic exchange of key clinical information*
and provides electronic summary of care record to another provider
for >50% of referrals
F8. Tracks referrals until consultant/specialist report is available,
flagging and following up on overdue reports CRITICAL FACTOR
F9. Documents co-management arrangements in patient’s medical
record
F10. Asks patients/families about self-referrals and requests reports
from clinicians
* Meaningful Use Requirement.
NOTE: Critical Factors in a Must-Pass Element are essential for Recognition.
30
PCMH 5B: Scoring
MUST PASS – 4 Points
Scoring
§ 9-10 Factors (including factor 8) = 100%
§ 7-8 Factors (including factor 8) = 75%
§ 4-6 Factors (including factor 8) = 50% MUST-PASS THRESHOLD
§ 2-3 Factors (including factor 8) = 25%
§ 0-1 Factors (or does not meet factor 8) = 0%
Must meet minimum of 4 Factors (including Factor 8) to pass this Must-Pass
Element and receive any level of Recognition.
31
PCMH 5B: Documentation
F1-10: Requirements
F1. Examples of types of information the practice has on specialist
performance
F2-3. At least one example for each factor
F4. Materials explaining how behavioral health is integrated with
physical health
F5-6. Documented process and at least one example or report
demonstrating process implementation
F7. Report from electronic system with numerator, denominator, and
percent At least 3 months of data
F6, 8, 10. Documented process and at least one example or report
demonstrating process implementation
F9. At least three examples
32
PCMH 5B: Example of Agreement
Source: www.ncqa.org
33
PCMH 5B: Example of CoManagement Procedure
Source: www.ncqa.org
34
PCMH 5B: Example of Clinical Reason/
Type/Timing
Source: www.ncqa.org
35
PCMH 5B: Example of Documented
Process
Source: www.ncqa.org
36
PCMH 5B: Example of Referral
Tracking Method
Tracking Table Includes:
Reason for referral
Purpose of referral
Date referral initiated
Timing to receive report
Source: www.ncqa.org
37
PCMH 6D: Implement Continuous
Quality Improvement
6D. Implement Continuous Quality Improvement Must Pass - 4 Points
The practice uses ongoing quality improvement process:
F1. Set goals and analyze at least three clinical quality measures from
Element 6A
F2. Act to improve performance on at least three clinical quality measures
from Element 6A
F3. Set goals and analyze at least one measure from Element 6B
F4. Act to improve at least one measure from Element 6B
F5. Set goals and analyze at least one patient experience measure from
Element 6C
F6. Act to improve at least one patient experience measure from Element
6C
F7. Set goals and address at least one identified disparity in care/service for
identified vulnerable populations
38
PCMH 6D: Scoring
MUST PASS – 4 Points
Scoring
§ 7 Factors = 100%
§ 6 Factors = 75%
§ 5 Factors = 50% MUST-PASS THRESHOLD
§ 1-4 Factors = 25%
§ 0 Factors = 0%
Must meet minimum of 5 Factors to pass this Must-Pass Element and receive any
level of Recognition.
39
PCMH 6D: Documentation
F1-7: Requirements
F1-7: Report
OR
F1-7: Completed PCMH Quality Measurement and
Improvement Worksheet (QIW)
40
PCMH 6D: Example of QI Worksheet
Click here
Source: www.ncqa.org
41
PCMH 6D and 6E: Example of QI
Worksheet
How to complete a row:
Use 3 Measures Identified in 6A 1. Measure Selected for Improvement & Reason for Selection Reason: We want to increase percentage of patients who receive
screening for CRC. Baseline Start Date: 5/1/14
2. & 3. Baseline Performance Measurement & Numeric Goal for
Improvement (6D 1) Measure 1:
Colorectal cancer
(CRC) screening Baseline End Date: 5/30/14
Baseline Performance Rate (% or #): 36.3%
Numeric Goal Rate (% or #): 58% Action : Pop up reminders were added to our EMR for patients due/
overdue screening
4. What actions were taken to improve and work towards goal?
Provide dates actions were initiated. (6D 2)
(Only 1 Action Required) Date Action Initiated: 7/1/14
Additional Actions Taken: Provider quality compensation metric put
in place to incentivize providers to ensure appropriate health
screening
5. Re-measure Performance (6E 2) Start Date: 5/1/15
End Date: 5/30/15
Rate (% or #): 69.2% 6. Assess Actions & Describe Improvement
(6E 1) Since September 2014, there has been an increase of 32.9% in
patients receiving CRC screening due to incentivizing providers and
use of clinical decision support of EMR to indicate when patients are
due for screening. 42
PCMH 6D and 6E: Example of QI
Worksheet (cont.)
Use 3 Measures Identified in 6A 1. Measure Selected for Improvement & Reason for Selection Reason:
Baseline Start Date:
2. & 3. Baseline Performance Measurement & Numeric Goal
for Improvement (6D 1) Measure 1:
Baseline End Date:
Baseline Performance Rate (% or #):
Numeric Goal Rate (% or #):
Action :
4. What actions were taken to improve and work towards
goal? Provide dates actions were initiated. (6D 2)
(Only 1 Action Required) 5. Re-measure Performance (6E 2) 6. Assess Actions & Describe Improvement
(6E 1) Date Action Initiated:
Additional Actions Taken: Start Date:
End Date:
Rate (% or #):
1. Measure Selected for Improvement & Reason for Selection Reason:
Baseline Start Date:
Measure 2:
2. & 3. Baseline Performance Measurement & Numeric Goal
for Improvement (6D 1) Baseline End Date:
Baseline Performance Rate (% or #):
Numeric Goal Rate (% or #):
Action :
4. What actions were taken to improve and work towards
goal? Provide dates actions were initiated. (6D 2)
(Only 1 Action Required) Date Action Initiated:
Additional Actions Taken: 43
For More Information
Visit NCQA Web Site at www.ncqa.org to:
§  Follow the Start-to-Finish Road Map to Recognition
§  View Frequently Asked Questions
§  View Recognition Programs Training Schedule
Other PCMH resources:
http://www.ncqa.org/Programs/Recognition/Practices/
PatientCenteredMedicalHomePCMH/DuringEarnItPCMH/
OtherPCMHResources.aspx
Set up an account and ask NCQA your questions:
https://my.ncqa.org/
View recorded webinars and trainings:
http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecognition/
RecognitionTraining/RecordedTrainings.aspx
Contact NCQA Customer Support by calling 1.888.275.7585
Monday-Friday, 8:30 a.m. - 5:00 p.m. EST
44
Thank you!
45