Report and Presentation

After reviewing the health records, conducting a patient visit with care planning, completing a comprehensive health assessment, and doing a medication management review, the student team will then write a draft of:

  • Their overall assessment and recommendations, following the format used by the practice, such as SOAP or SBAR
  • A patient care plan (for information on components, see Patient Encounter section)

The students will then present these to the practice team (e.g., the patient’s providers and/or students’ preceptors), who will work with the student team to make any appropriate revisions. Having the patient and/or family/caregiver invited to the presentation is an option.

The review meeting between the interprofessional team of students and the practice team should ideally include at least two relevant professions from the practice team. This meeting often occurs on another day of the week than the patient visit, and may include presentations from other patient visits and other Clinical Interprofessional Curriculum (CIPC) activities.

Student presentations should follow a standard format, such as SBAR or SOAP. The written plan and presentation will incorporate findings from all of care management activities. At a time that is appropriate, such as after the student meeting with the practice team, the final care plan, that is revised (if needed) and approved by the practice team, is presented in writing to the patient and/or family/caregiver. The written individualized care plan is tailored to account for health literacy and language considerations (Standard 4 Element B, Care Planning and Self-Care Support, Factor 5). 

Resources:

Student Learning Objectives:

  • Develop a review, assessment, and plan for a patient that includes comprehensive health assessment, a medication management review, and/or a care plan that includes a patient visit, which can be a home visit. The care management activities should: assist patients and their family/caregivers in managing their conditions; improve their health care; and reduce health costs.
  • Develop and implement at least two health literacy skills from the AHRQ Health Literacy Universal Precautions Toolkit.
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members (IPEC VE6, CICH 2010)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Use unique and complementary abilities of all members of the team to optimize patient care. (IPEC RR9)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Engage other health professional – appropriate to the specific care situation – in shared patient-centered problem-solving. (IPEC TT3)
  • Integrate the knowledge and experience of other professions— appropriate to the specific care situation — to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Reflect on individual and team performance for individual, as well as team, performance improvement. (IPEC TT8)

Standard 4, Element A: Identify Patients for Care Management

The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of the following:

  • Factor 1: Behavioral health conditions.
  • Factor 2: High cost/high utilization.
  • Factor 3: Poorly controlled or complex conditions.
  • Factor 4: Social determinants of health.
  • Factor 5: Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver).
  • Factor 6: The practice monitors the percentage of the total patient population identified through its process and criteria. (critical factor)

The intent of the element is that practices use defined criteria to identify true vulnerability—a single criterion, such as cost, may not be an appropriate indicator of need for care management. Although patients can be identified for care management by diagnosis or condition, the emphasis of care must be on the whole person over time and on managing all of the patient’s care needs. The practice adopts evidence-based guidelines and uses them to plan and manage patient care.

The practice may identify patients through a billing or practice management system or electronic medical record; through key staff members; or through profiling performed by a health plan, if profiles provided by the plan represent at least 75 percent of the patient population.

The practice considers how its comprehensive health assessment (PCMH 3, Element 3C) supports establishing criteria and a systematic process for identifying patients for care management.

The practice receives credit for each factors (1–5) included in its criteria for identification of patients for care management. A patient may fall into more than one category (factor) and may be included in some or all of these counts. The practice uses criteria to create a registry of patients identified as likely to benefit from care management. There may be more than one set of processes and criteria to identify specific types of patients.

Factor 1

The practice has specific criteria for identifying patients with behavioral conditions for whole-person care planning and management.

Criteria are developed from a profile of patient assessments, and may include the following, or a combination of the following:

  • A diagnosis of a behavioral issue (e.g., visits, medication, treatment or other measures related to behavioral health).
  • Psychiatric hospitalizations (e.g., two or more in the past year).
  • Substance use treatment.
  • A positive screening result from a standardized behavioral health screener (including substance use).

Pediatric populations

Practices may identify children and adolescents with special health care needs, defined by the U.S. Department of Health and Human Services Maternal and Child Health Bureau (MCHB) as children “who have or are at risk for chronic physical, developmental, behavioral or emotional conditions and who require health and related services of a type or amount beyond that required generally.” (Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, American Academy of Pediatrics, 3rd Edition, 2008, p. 18.)

Factor 2

The practice has specific criteria for identifying patients who experience high utilization or high cost. The practice may consider the following when establishing criteria:

  • ER visits
  • Hospital re-admissions
  • Unusually high numbers of imaging or lab tests ordered
  • Unusually high number of prescriptions
  • High-cost medications
  • Number of secondary specialist referrals
  • Reports, alerts or other notifications from health plans indicating high cost or high utilization

Factor 3

The information and process for identifying high-cost/utilization patients may differ from the process for identifying poorly controlled patients (e.g., with continued abnormally high A1C or blood pressure results). Patients who consistently fail to meet treatment goals or with multiple co-morbid conditions may be included in the criteria for this factor.

Factor 4

The practice has a process for identifying patients based on social determinants of health. Social determinants of health are conditions in the environment that affect a wide range of health, functioning and quality-of-life outcomes and risks. Examples include: availability of resources to meet daily needs; access to educational; economic and job opportunities; public safety, social support; social norms and attitudes; exposure to crime, violence and social disorder; socioeconomic conditions; residential segregation and others (Healthy People 2020).

Factor 5

The practice has a process based on these criteria that is intended to allow for referrals by external entities and nominations by those closest to patients/families/caregivers.

Factor 6 

Assessment of a combination of factors 1–5 results in a subset of the practice’s entire panel of patients identified as likely to benefit from care management.

Note: Patients identified in this element will be used to draw a sample for the medical record review required in PCMH 4, Element 4B and Element 4C.

Documentation

Factors 1–5: NCQA reviews the practice’s documented process that describes the criteria for identifying patients for each factor.

Factor 6: NCQA reviews a report showing the number and percentage of its total patient population identified as likely to benefit from care management.

The practice calculates a percentage that requires a numerator and a denominator. The practice may use the following methodology to calculate the percentage:

  • Denominator = Total number of patients in the practice.
  • Numerator = Number of unique patients identified in the denominator as likely to benefit from care management by the criteria in factors 1–5.

Note: The practice must identify at least 30 patients in the numerator for factor 6 to use in reporting Element 4B and Element 4C.


Standard 3, Element C: Comprehensive Health Assessment

To understand the health risks and information needs of patients/families, a comprehensive health assessment includes:

  • Factor 1: Age and gender appropriate immunizations and screenings
  • Factor 2: Family/social/cultural characteristics
  • Factor 3: Communication needs
  • Factor 4: Medical history of patient and family
  • Factor 5: Advance care planning (not applicable for pediatrics)
  • Factor 6: Behaviors affecting health
  • Factor 7: Mental health/substance abuse history of patient and family
  • Factor 8: Developmental screening using a standardized tool (for pediatrics)
  • Factor 9: Depression screening for adults and adolescents using a standardized tool
  • Factor 10: Assessment of health literacy

Details of Comprehensive Health Assessment:

In additional to a physical assessment, a standardized, comprehensive patient assessment includes an examination of social and behavioral influences. Complex patients with an active diagnosis or aspect of care listed in the problem list of their care summary are reassessed at each relevant visit. The practice should consider how its comprehensive health assessment helps establish criteria and supports a systematic process for identifying patients for care management in PCMH 4 Element A.

Factor 1 

The practice implements age/gender-appropriate screenings and immunizations, when possible, using immunizations identified by the U.S. Preventive Services Task Force (USPSTF); the Centers for Medicare & Medicaid Services (CMS) in Provider Quality Reporting System (PQRS); NCQA’s Child Health measures; immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC); preventive care and screenings for children and for women, as recommended by the Health Resources and Services Administration (HRSA); or other standardized preventive measures, including those identified in Bright Futures for pediatric patients.

Factor 2

The health assessment includes an evaluation of social and cultural needs, preferences, strengths and limitations. Examples of these characteristics can include family/household structure, support systems, household/environmental risk factors, and patient/family concerns. Broad considerations should be made for a variety of characteristics (e.g., poverty, homelessness, unemployment, sexual orientation, gender, education level, social support).

Factor 3 

The practice identifies whether the patient has specific communication requirements due to hearing, vision or cognition issues. This does not address language; refer to PCMH 3A, factor 5.

Factor 4

Family medical history (e.g., history of chronic disease or event [e.g., diabetes, cancer, substance abuse, hypertension]) for “first–degree” relatives (i.e., who share about 50 percent of their genes with a specific family member).

The practice may document “unknown” for patients who do not know their family medical history.

Factor 5

The practice documents patient/family preferences for advance care planning (i.e., care at the end of life or for patients who are unable to speak for themselves). This may include discussing and documenting a plan of care, with treatment options and preferences. Patients with an advance directive on file meet the factor requirement.

This factor is met if the practice sees only pediatric patients and documents “NA” in the field. The practice provides a written explanation for an NA response in the Support Text/Notes box in the Survey Tool. Documentation that the patient declined to provide information counts toward the numerator.

Factor 6

Assessment of risky and unhealthy behaviors goes beyond physical activity and smoking status; it may include nutrition, oral health, dental care, familial behaviors, risky sexual behavior and secondhand smoke exposure.

Factor 7

The practice assesses whether the patient and the patient’s family has mental health/behavioral conditions or substance abuse issues (e.g., stress, alcohol, prescription drug abuse, illegal drug use, maternal depression).

Factor 8 

For newborns through 3 years of age, periodic developmental screening uses a standardized screening test. If there are no established risk factors or parental concerns, screens are done by 24 months.

This factor is met if the practice sees only adult patients and documents “NA” in the field. The practice provides a written explanation for an NA response in the Support Text/Notes box in the Survey Tool.

Factor 9

The U.S. Preventive Services Task Force (USPSTF) states that adults and adolescents should be screened for depression when the practice has access to services that can be used if there is a positive result (e.g., mental health providers in the practice or external to the practice and to whom the practice can refer patients).

  • Screening for adults: Screening adults for depression when staff-assisted depression care support systems are in place to assure accurate diagnosis, effective treatment and follow-up. Practices use a standardized screening tool (e.g., PHQ-9). A standardized tool collects information using a current evidence-based approach that has been developed, field-tested and endorsed by a national or regional organization.
  • Screening for adolescents (12–18 years): Screening for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal) and follow-up.

This factor is met if the practice sees no adolescent or adult patients and documents “NA” in the field. The practice must provide a written explanation for an NA response in the Support Text/Notes box in the Survey Tool.

This factor is not met if the practice does not screen for depression or if screening is not performed with a standardized tool.

Factor 10

The practice assesses the patient/family/caregiver’s ability to understand the concepts and care requirements associated with managing their health.

Alternatively, the practice demonstrates it is a health literate organization (e.g., apply universal precautions, provide health literacy training for staff, system redesign to serve patients at different health literacy levels, utilize AHRQ’s or Alliance for Health Reform’s Health Literacy toolkit, etc.). Health literate organizations understand that lack of health literacy leads to poorer health outcomes and compromises patient safety and have taken action to ensure there are processes established that address health literacy to improve health behavior and patient safety in the practice setting. 

Health literacy resources

Documentation

Factors 1–10: The practice chooses one of these two methods of documentation:

  1. Practice system generated report with a numerator and denominator based on all unique patients in a recent 3 month period. The report must clearly indicate how many patients had an assessment for each factor. The report must indicate that data was entered in the medical record for more than 50 percent in order for the practice to respond “yes” to each factor in the survey tool. 
    OR
  2. Review the patient records selected for the medical record review as required in elements 4B and 4C and document presence or absence of the information in the Record Review Workbook. For each factor to which the practice responds “yes,” it provides one example of how it meets the factor.

Factors 8, 9: In addition to the method chosen, the practice must provide a completed form (de-identified) for each of these factors to receive credit.

Factor 10: For practices that do not assess health literacy at the patient level, NCQA reviews materials or processes demonstrating that health literacy is addressed at the practice.


Standard 4, Element C: Medication Management

The practice has a process for managing medications, and systematically implements the process in the following ways:

  • Factor 1: Reviews and reconciles medications for more than 50% of patients received from care transitions (CRITICAL FACTOR).
  • Factor 2: Reviews and reconciles medications with patients/families for more than 80% of care transitions.
  • Factor 3: Provides information about new prescriptions to more than 80% of patients/families/caregivers.
  • Factor 4: Assesses understanding of medications for more than 50% of patients/families/caregivers, and dates the assessment.
  • Factor 5: Assesses response to medications and barriers to adherence for more than 50% of patients, and dates the assessment.
  • Factor 6: Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients, and dates updates.

Assessment of this element is based on a sample of patients identified in Standard 4 Element A (Identify Patients for Care Managment). The same patients are used for the assessment in Standard 3 Element C (Comprehensive Health Assessment), and the care plan in Standard 4 Element B (Care Planning and Self-Care Support).

Factors 1, 2

Factor 1 is a critical factor and is required for practices to receive a score on this element.

The practice reviews and documents in the medical record all prescribed medications the patient is taking. Medication review and reconciliation occurs, at least annually, at transitions of care and at relevant visits. The practice may use its own criteria to determine a relevant visit.

Maintaining a list of current medications and resolving medication conflicts reduces the possibility of duplicate medications, medication errors and adverse drug events. A process for reconciling medications is essential for patient safety.

Factor 3

The practice provides patients/families with information about a new medication, including potential side effects, drug interactions, instructions for taking the medication and the consequences of not taking it.

Factor 4

The practice assesses how well patients understand the information about medications they are taking, and considers a patient’s health literacy (PCMH 3, Element C, factor 10).

Factor 5

The practice asks patients about a problem or difficulty taking a medication; whether they are experiencing side effects; and whether the medication is being taken as prescribed. If a patient is not taking a medication as prescribed, the practice determines why.

Factor 6

At least annually, the practice reviews and documents in the medical record the nonprescription medications, such as over-the-counter (OTC) medications, herbal therapies and supplements that the patient is taking to prevent interference with prescribed medication and to evaluate potential side effects.

Documentation

Factors 1–6: NCQA reviews reports from the practice’s electronic system OR the Record Review Workbook. If using the Record Review Workbook examples are required demonstrating how each factor is documented.

The practice calculates a percentage that requires a numerator and a denominator, using one of the following methods.

Method 1: Query the practice’s electronic registry, practice management system or other electronic systems for the patients identified in Element A. This method is used if the practice can determine a denominator, as described below.

  • Denominator = Total number of patients identified through the criteria in Element A seen at least once for a relevant visit by the practice in a recent three-month period.
  • Numerator = Number of patients identified in the denominator for whom each item is entered in the medical record.

Note: At least 30 patients must be included in the sample for Method 1.

Method 2: Use the instructions in the Record Review Worksheet to choose a sample of relevant patients and check for the relevant items. For each factor to which the practice responds “yes,” it provides an example of how it meets the factor.

“NA” is an option in the Record Review Workbook drop-down menu for each factor in this element and may be used for patients who have not been prescribed any medication.


Standard 4, Element B: Care Planning and Self-Care Support (MUST PASS)

The 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% of the patients identified in Element A:

  • Factor 1: Incorporates patient preferences and functional/lifestyle goals
  • Factor 2: Identifies treatment goals
  • Factor 3: Assesses and addresses potential barriers to meeting goals
  • Factor 4: Includes a self-management plan
  • Factor 5: Is provided in writing to the patient/family/caregiver

MUST-PASS elements are considered the basic building blocks of a patient centered medical home. Practices must earn a score of 50% or higher. All six must-pass elements are required for recognition.

The care team and patient/family/caregiver collaborate on developing and updating an individualized care plan that addresses whole-person care. The care plan specifies the services offered by and responsibilities of the primary care practice and, if appropriate, integrates with a care plan created for the patient by a non-primary care specialty practice, to avoid potential overlap or gap in services and care.

A care plan considers and/or specifies various areas related to a patient’s care, which could include:

  • Patient preferences and functional/lifestyle goals
  • Treatment goals
  • Assessment of potential barriers to meeting goals
  • Strategies for addressing potential barriers to meeting goals
  • Care team members, including the primary care provider of record and team members beyond the referring or transitioning provider and the receiving provider
  • Current problems (may include historical problems, at the practice’s discretion)
  • Current medications
  • Medication allergies
  • A self-care plan

CMS defines a care plan as, “The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).”

Factor 1

The practice works with patients/families/caregivers to incorporate patient preferences and functional lifestyle goals in the care plan and updates the plan at relevant visits. A relevant visit addresses an aspect of care that will affect progress toward meeting existing goals or that requires modification of an existing goal.

Factor 2

The practice works with patients/families/caregivers and other providers to develop treatment goals using evidence-based guidelines.

Factor 3

The practice works with patients/families/caregivers, other providers and community resources to assess and address potential barriers to achieving treatment and functional/lifestyle goals.

Factor 4

The practice works with patients/families/caregivers to develop a self- management plan. Patients/family/caregivers that manage complex conditions or may have other significant potential barriers (factor 3) are given instructions and resources, as appropriate.

The self-management plan includes goals and a way to monitor self-care.

If the patient is meeting treatment goals, documentation could be that the patient is meeting treatment goals with documentation that the patient was instructed to maintain the current self-care plan.

Factor 5

The written individualized care plan is given to the patient/family/caregiver. When possible, the plan is tailored to account for health literacy and language considerations.

Documentation

Factors 1–5: NCQA reviews reports from the practice’s electronic system, OR the Record Review Workbook. If using the Record Review Workbook examples are required demonstrating how each factor is documented.

The practice calculates a percentage that requires a numerator and a denominator using one of the following methods.

Method 1: Query the practice’s electronic registry, practice management system or other electronic systems for the patients identified in Element A. This method is used if the practice can determine a denominator, as described below.

  • Denominator = Total number of patients identified through the criteria in Element A seen at least once for a relevant visit by the practice in a recent three-month period.
  • Numerator = Number of patients identified in the denominator for whom each item is entered in the medical record.

Note: At least 30 patients must be included in the sample for Method 1.

Method 2: Use the instructions in the Record Review Workbook to choose a sample of relevant patients and check for the relevant items. For each factor to which the practice responds “yes,” it provides an example of how it meets the factor.