Learning Objectives To identify the easiest elements to meet To identify the most challenging standards and elements (Must Pass and Critical Factors) Must Pass (1A, 2D, 3C, 4A, 5B, 6C) Critical Factors: 1A Factor 1 (Also a Must Pass Element) 1B Factor 3 1G Factor 2 3A Factor 3 3D Factor 1 3E Factor 2 4A Factor 3 (Also a Must Pass Element) 5A Factors 1 and 2 To gain an understanding of how to use NCQA’s Record Review Workbook to support PCMH 3C,3D and 4A. Our speaker Candace J. Chitty, BSN, MBA, CPHQ, PCMH-CCE is a NCQA PCMH reviewer and an expert in the NCQA patient centered medical home model and recognition process

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Candace J. Chitty
MBA, CPHQ, PCMH-CCE
Bonni Van, RN, MBA

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Learning Objectives
 To identify the easiest elements to meet
 To identify the most challenging standards and elements
(Must Pass and Critical Factors)
 Must Pass (1A, 2D, 3C, 4A, 5B, 6C)
 Critical Factors:
1A Factor 1 (Also a Must Pass Element)
1B Factor 3
1G Factor 2
3A Factor 3
3D Factor 1
3E Factor 2
4A Factor 3 (Also a Must Pass Element)
5A Factors 1 and 2
 To gain an understanding of how to use NCQA’s Record
Review Workbook to support PCMH 3C,3D and 4A.

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There are some elements that practice’s seem to find easier than
others to complete. Based solely on our experience working with
clients through the PCMH process and experience as a NCQA
External PCMH reviewer we created our “Easy Street” List:
PCMH 1D – Continuity – Personal Clinician
PCMH 1E - Medical Home Responsibilities
PCMH 1F - Culturally and Linguistically Appropriate Services
PCMH 4B – Referrals to Community Resources
PCMH 2C – Comprehensive Health Assessment Practices with
EHR’s and participating in MU.
PCMH 2A – Patient Information(Particularly Factors 1-5 –Core MU
Demographics)
PCMH 2B - Clinical Data (Stage 1 MU when practices have
attested to MU and review MU performance on a
regular basis

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 There are 6 Must Pass elements
 All must be passed at 50% in order to be PCMH recognized. What
does that mean? You have to meet all requirements within the 50%
scoring table for each of the must pass elements.

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All must pass elements can be passed
without an electronic medical record but
some may be more challenging than others.
(e.g., PCMH 2D)
TIP: It is recommended you strive to meet
100% but at minimum work to meet 75%.
This provides a scoring “cushion” should a
factor be scored negatively by a reviewer.

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 A critical factor is a factor that is identified as an
important aspect of a particular element.
 Some elements with a critical factor will result in
0% if not met (PCMH 1A, 3E, and 5A)
 In others a practice can only achieve a minimum
score of 25% when the critical factor is not met.
 One element that contains 2 critical factors.
(PCMH 5A)
 2 must pass elements also contain a critical factor.
(PCMH 1A and 4A).

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PCMH 1A – Enhance Access and Continuity
Must Pass and 1 Critical Factor – 0% (0 points out
of a possible 4 points) if critical factor not met.

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PCMH 1A – Enhance Access and Continuity
Challenges and Key Points:
 Each factor requires 3 components to be considered a
“Yes”
Documented Process
Standards of Performance
Monitoring
 Measuring access (same day appt and clinical advice
by telephone and secure messaging)
 Reserving time each day across the practice for same
day appointment. Cannot use a work-in process or fill
the day’s schedule based on no-shows or
cancelations.
 Understanding the definition of clinical advice.

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Factor 3: Providing timely clinical advice by telephone
when the office is not open.
Can only receive 25% (1 point out of a possible 4 points)
Challenges and Key Points:
 Requires 3 components to be considered a “Yes”
Documented Process
Standards of Performance
Monitoring
 After Hours services often only collect the time the call
came in and the time dispatched to the provider.
 Providing a summary of results in the timeliness report.

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Having regular team meetings or a structured
communication process.
Can only receive 25% (1 point out of a
possible 4 points)
Challenges and Key Points:
 Documenting the care team’s communication
process (huddle or other means)
 If the communication process is primarily
verbal document a week of communication
for survey purposes.

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PCMH 2D – Use Data for Population Health
Management
Must Pass– Must meet 2 of the 4 factors to reach 50%
(2.5 points out of a possible 5 points).

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Intent: Demonstrate a “proactive” approach to managing your
overall patient population. Showing NCQA how do you use patient
data and evidenced based guidelines to generate lists AND
remind patients about needed services
Challenges and Key Points:
 Each of the four factors requires a patient listing (showing the
need for each type of service) along with at least 1 example of
each reminder type.
 Lack of functionality to generate lists of patients needing a
service.
 Providing lists of patients but no evidence of reminders
 Not clearly evidencing patient lists generated within the last 12
months

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Implementing Evidence-Based Guidelines:
Identifying a third important condition, related
to an unhealthy behaviors or mental health or
substance abuse
Can only receive 25% (1 point out of a possible 4
points)
Challenges and Key Points:
 Not meeting this factor means you will not meet
any of the Record Review Workbook elements
(PCMH 3C, 3D and 4A) Two of these elements
are Must Pass.

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PCMH 3C – Care Management
Must Pass– Must meet at least 3 of the 7 factors to reach 50%
(2.0 points out of a possible 4 points).

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Medication Management: Reviews and reconciles medications
with patient/families for more than 80% of care transitions
Part of Record Review Workbook
Can only receive 0% (0 points out of a possible 3 points)
Challenges and Key Points:
 Finding documentation in the sampled medical records of
medication review and reconciliation following visits to
specialists, as well as ER visits and hospitalizations.
Medication review and reconciliation should occur at
transitions of care and at relevant visits at least annually.
 Assess early in your PCMH process if and where this is being
documented.

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Use of E-Prescribing: Generates at least 75% of
eligible prescriptions.
Can only receive 25% ( points out of a possible 3
points)
Challenges and Key Points:
 Can be difficult to document when fully
transitioned to e-prescribing.
 Not evidencing this factor using reports.
NOTE: If the practices percentage results for factor
1 (Generates ad transmits at least 40% of eligible
prescriptions to pharmacies) is at least 75% the
practice automatically can score “yes”.

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PCMH 4A – Support Self-Care Process
6 Factors
Included as part of the Record Review Workbook
 Must Pass– Must meet at least 3 of the 6 factors
including Factor 3 to reach 50% (3 points out of a
possible 6 points).
 Factor 3 is a Critical Factor – Can only achieve 25% if
this factor is not met. Not meeting the factor will
result in Not meeting the Must Pass and the practice
will not be recognized.
Factor 3 can be challenging because it requires
identifying agreed upon goals and a way to monitor
self-care.

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Test Tracking and Follow-Up
Factor 1:Tracks lab tests until results are available, flagging
and following up on overdue results
Factor 2: Tracks imaging tests until results are
available, flagging and following up on overdue results
The practice receives 0% (0 point out of a possible 6
points) if both factors are not met
Challenges and Key Points:
 Must have a documented process AND be able to
demonstrate the follow-up.
 Process for f/u on overdue results should be proactive.
 Written process along with a report or log showing the
tracking and examples of how the process it met for
EACH factor.

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Must Pass at 50% (3 points out of a possible 6 points)

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Challenges and Key Points:
General: Practices have the option to restrict referral tracking to
“important” referrals or track all.
Factor 1: Show NCQA (screenshot, paper referral) for the pertinent
clinical information sent to the specialist.
Factor 2 and 3 :Make sure you show NCQA what your required timing is
for receiving specialist reports and how you follow-up when that
timeframe is overdue.
Factor4: This is difficult requiring a practice to provide a documented
process of PCP and specialist mutually agreed upon exchange of
information when patients are co-managed and 3 examples of such
Factor 5: Must have a proactive approach to asking patients about self
–referrals and to f/u for reports. NCQA requires 3 examples.
Data must be REAL (de-identified) patient data.

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Challenges and Key Points:
 2 Must Pass elements included.
 REMEMBER: You must include a sample of patients from
PCMH 3A Factor 3 in order to meet any factors in
3C, 3D, and 4A.
 A practice does not have to use the RRW but it is strongly
recommended because it is technically challenging to
accurately report using Method 1 (querying the practice’s
electronic systems for the important conditions)
 Do not use conditions in the RRW that are different from
PCMH 3A and 3B.
 If you respond to PCMH 3B include selected patients in the
RRW.
 If you do not respond to PCMH 3B do not include a selected
patient sample.

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Challenges and Key Points:
 A practice must select 48 medical records regardless of how many
important conditions the practice responds to and whether the
practice chooses a high risk/complex patient population.
 It is important when selecting conditions in PCMH 3A and 3B the
practice select those that benefit from care management, have
evidence-based guidelines, and systems that can embed use of
guidelines in clinical operations.
 Follow the sampling methodology carefully outlined in the RRW
instructions.
 View the RRW training video provided by NCQA
http://www.youtube.com/watch?v=lITAOlJOqwc
 Other recorded trainings can be found at the following link.
http://www.ncqa.org/Programs/Recognition/RelevanttoAllRecog
nition/RecognitionTraining.aspx#PCMHTrainings

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Mark your
Calendars.
Friday, July 19th.
The next session in
the PolicyPLUS PCMH
Webinar Series:
Telling your
PCMH Story
Best Strategies for
Presenting your
Documentation
Questions & Answers
Thank you for participating in the PolicyPLUS
PCMH Webinar series. If you have any
comments or additional questions please
do not hesitate to contact us at:
CJChitty@Qfhc.com RChitty@Qfhc.com
www.Qfhc.com www.Qfms.org