Version 11.5 Patient-Centered Medical Home (PCMH) 2014 Reference Guide for Sevocity Users

Transcription

1 Version 11.5 Reference Guide for Sevocity Users

2 Table of Contents Product Support Services... 3 Introduction to PCMH PCMH 2014 Scoring... 5 PCMH 2014 Meaningful Use Alignment... 7 PCMH 2014 Summary Approval Table... 8 Letter of Product Autocredit Approval... 9 Prevalidation Step-by-Step Guide for Client Practices PCMH 1: Patient-Centered Access Element A: Patient-Centered Appointment Access Element B: 24/7 Access to Clinical Advice Element C: Electronic Access PCMH 2: Team-Based Care Element A: Continuity Element B: Medical Home Responsibilities Element C: Culturally and Linguistically Appropriate Services Element D: The Practice Team PCMH 3: Population Health Management Element A: Patient Information Element B: Clinical Data Element C: Comprehensive Health Assessment Element D: Use Data for Population Management Element E: Implement Evidence-Based Decision Support PCMH 4: Care Management and Support Element A: Identify Patients for Care Management Element B: Care Planning and Self-Care Support Element C: Medication Management Element D: Use Electronic Prescribing Element E: Support Self-Care and Shared Decision Making PCMH 5: Care Coordination and Care Transitions Element A: Test Tracking and Follow-Up Element B: Referral Tracking and Follow-Up Element C: Coordinate Care Transitions PCMH 6: Performance Measurement and Quality Improvement Element A: Measure Clinical Quality Performance Element B: Measure Resource Use and Care Coordination Page 2 of 61

3 Element C: Measure Patient/Family Experience Element D: Implement Continuous Quality Improvement Element E: Demonstrate Continuous Quality Improvement Element F: Report Performance Element G: Use Certified EHR Technology Product Support Services As always, Sevocity comes with outstanding support and training. For any questions not answered in this user reference guide or the online help system found under the Help menu in Sevocity, please contact one of our Support Specialists. Support Specialists can be contacted at , or via our Contact Us option under the Help menu in Sevocity. Page 3 of 61

4 Introduction to PCMH 2014 Introduction to PCMH 2014 The National Committee for Quality Assurance s (NCQA) Patient-Centered Medical Home (PCMH) recognition program is a model of care that organizes primary care with a focus on care coordination and communication among providers to yield higher quality care at lower costs. Sevocity v is NCQA Prevalidated for PCMH to receive 9.75 points in autocredit toward the PCMH 2014 program. The PCMH 2014 Reference Guide for Sevocity Users has been generated to assist Sevocity users with NCQA/PCMH guidelines and reporting. The information contained within is based on the NCQA-published PCMH Standards and Guidelines, This guide is designed as a supplemental document and is not a substitute for the PCMH Standards and Guidelines provided by NCQA. For full program requirements and specifics, please refer to the NCQA PCMH Recognition website: PCMH 2014 Standards PCMH 2014 Standards PCMH Standard 1: Patient-Centered Access PCMH Standard 2: Team-Based Care PCMH Standard 3: Population Health Management PCMH Standard 4: Care Management and Support PCMH Standard 5: Care Coordination and Care Transitions PCMH Standard 6: Performance Management and Quality Improvement Page 4 of 61

5 PCMH 2014 Scoring PCMH 2014 Scoring There are three levels of NCQA PCMH Recognition. Each level reflects the degree to which a practice meets the requirements of the elements and factors that comprise the standards. The NCQA Recognition levels allow practices with a range of capabilities and sophistication to meet the standards requirements successfully. The point allocation for the three levels is as follows. Scoring Summary Recognition Levels Required Points Must-Pass Elements Level points 6 of 6 elements are required Level points for each level. Score for each Must-Pass Level points element must be 50% 100 Points, 27 Elements, 6 Must-Pass Elements Points Standard/Element Must-Pass 10 PCMH 1: Patient-Centered Access 4.5 Element A: Patient-Centered Appointment Access 3.5 Element B: 24/7 Access to Clinical Advice 2 Element C: Electronic Access 12 PCMH 2: Team-Based Care 3 Element A: Continuity 2.5 Element B: Medical Home Responsibilities 2.5 Element C: Culturally & Linguistically Appropriate Services (CLAS) 4 Element D: The Practice Team 20 PCMH 3: Population Health Management 3 Element A: Patient Information 4 Element B: Clinical Data 4 Element C: Comprehensive Health Assessment 5 Element D: Use Data for Population Management 4 Element E: Implement Evidence-Based Decision Support 20 PCMH 4: Care Management and Support 4 Element A: Identify Patients for Care Management 4 Element B: Care Planning and Self-Care Management 4 Element C: Medication Management 3 Element D: Use Electronic Prescribing 5 Element E: Support Self-Care and Shared Decision Making Page 5 of 61

6 PCMH 2014 Scoring Points Standard/Element Must-Pass 18 PCMH 5: Care Coordination and Care Transitions 6 Element A: Test Tracking and Follow-Up 6 Element B: Referral Tracking and Follow-Up 6 Element C: Coordinate Care Transitions 20 PCMH 6: Performance Measurement and Quality Improvement 3 Element A: Measure Clinical Quality Performance 3 Element B: Measure Resource Use and Care Coordination 4 Element C: Measure Patient/Family Experience 4 Element D: Implement Continuous Quality Improvement 3 Element E: Demonstrate Continuous Quality Improvement 3 Element F: Report Performance Not Scored Element G: Use Certified EHR Technology Page 6 of 61

7 PCMH 2014 Meaningful Use Alignment PCMH 2014 Meaningful Use Alignment The NCQA developed the PCMH recognition program to align with the Centers for Medicare & Medicaid Services (CMS) Meaningful Use criteria. The following factors align with Meaningful Use Modified Stage 2 objectives: PCMH Standard, Element, Factor Meaningful Use Modified Stage 2 Objective PCMH 1, Element C, Factor 1 Objective 8: Patient Electronic Access, Measure 1 PCMH 1, Element C, Factor 2 Objective 8: Patient Electronic Access, Measure 2 PCMH 1, Element C, Factor 4 Objective 9: Secure Messaging PCMH 3, Element E, Factors 1 6 Objective 2: Clinical Decision Support, Measure 1 PCMH 4, Element C, Factor 1 PCMH 4, Element D, Factor 1 Objective 7: Medication Reconciliation Objective 4: Electronic Prescribing PCMH 4, Element D, Factor 2 Objective 3: Computerized Provider Order Entry, Measure 1 PCMH 4, Element D, Factor 3 Objective 2: Clinical Decision Support, Measure 2 PCMH 4, Element E, Factor 1 Objective 6: Patient Specific Education PCMH 5, Element A, Factor 7 Objective 3: Computerized Provider Order Entry, Measure 2 PCMH 5, Element A, Factor 8 Objective 3: Computerized Provider Order Entry, Measure 3 PCMH 5, Element B, Factor 7 PCMH 5, Element C, Factor 7 PCMH 6, Element G, Factor 2 Objective 5: Health Information Exchange Objective 5: Health Information Exchange Objective 1: Protect Patient Health Information PCMH 6, Element G, Factor 3 Objective 10: Public Health Reporting, Measure Option 2 PCMH 6, Element G, Factor 4 Objective 10: Public Health Reporting, Measure Option 3 PCMH 6, Element G, Factor 5 Objective 10: Public Health Reporting, Measure Option 3 PCMH 6, Element G, Factor 7 Objective 10: Public Health Reporting, Measure Option 1 Page 7 of 61

8 NCQA PCMH 2014 Summary Approval Table Sevocity version 11.5 Points Approved Standard and Element Autocredit Factors Supporting Factors 1 Patient-Centered Access A Patient-Centered Appointment Access (Must Pass) 0.75 B 24/7 Access to Clinical Advice 1 2, 3, C Electronic Access 5, 6 2, 3 2 Team-Based Care 0.75 A Continuity 1 2 B Medical Home Responsibilities 3 C Culturally and Linguistically Appropriate Services 1, 2 D The Practice Team (Must Pass) 4 3 Population Health Management 0.75 A Patient Information 1, 3, B Clinical Data 6, 7 1-5, 8, 9 C Comprehensive Health Assessment 1, 4, 6-9 D Use Data for Population Health Management (Must Pass) E Implementing Evidence-Based Decision Support 1, 2, 3 4 Care Management and Support A Identify Patients for Care Management 1 B Care Planning and Self-Care Support (Must Pass) 5 C Medication Management 1, 2, D Use Electronic Prescribing 3, 4 2 E Support Self-Care and Shared Decision Making 1, 6 5 Care Coordination and Care Transitions 3.00 A Test Tracking and Follow-Up B Referral Tracking and Follow-Up (Must Pass) 8, 7 C Coordinate Care Transitions 6 Performance Measurement and Quality Improvement A Measure Clinical Quality Performance 1-3 B Measure Resource Use and Care Coordination C Measure Patient/Family Experience D Implement Continuous Quality Improvement (Must Pass) E Demonstrate Continuous Quality Improvement 1-2 F Report Performance G Use Certified EHR Technology Points 20 Factors 48 Factors Practice/Group Name: Implementation Date: Approved Conditions (if applicable): ADHD, Asthma, Anti-Depressant Medication Management, BMI Screening, Clinical Depression and Follow-Up Plan, Diabetes (Eye, Foot & Urine Screening), Hypertension, Pharyngitis, Pneumonia Vaccine, Tobacco Use Product Validation Date: 6/1/2015

9 PCMH 2014 Prevalidation Program Letter of Product Autocredit Approval Marcela Reyes Sevocity, A Division of Conceptual Mindworks 9830 Colonnade Blvd. Ste 377 San Antonio, TX Re: Sevocity version 11.5 Dear Ms. Reyes, June 1, 2015 NCQA would like to congratulate Sevocity, A Division of Conceptual Mindworks, on developing the Sevocity v solution which has been awarded a total of 9.75 points in PCMH 2014 Autocredit. As of 6/1/2015, Sevocity client practices utilizing Sevocity version 11.5 may benefit from reduced documentation and have scoring associated with awarded Autocredit applied to their total PCMH 2014 Survey score. This is contingent upon the vendor meeting the requirements outlined in the NCQA Prevalidation Handbook and practices following the Prevalidation Step-by-Step Guide for Client Practices. (attached) Prevalidated solutions are listed on the NCQA Prevalidation webpage: along with a link to the vendor s website: and a vendor pcmh@sevocity.com for those seeking product-related information. NCQA does not publicly share details on awarded autocredit or vendor reviews and practices must receive this directly from the vendor. In order for awarded autocredit to be applied to their total score, eligible practices must attest to the implementation and use of the prevalidated solution for associated autocredit points. This attestation is located in the organizational background section of the ISS survey tool, under the Prevalidation tab. Points awarded are detailed in the vendor s Summary Approval Table. (attached) Product Name Factors Approved for Autocredit Total Autocredit Awarded Sevocity v B:1; 1C:5&6; 2A:1; 3A:1,3&9; 3B:6&7; 3E:1-3; 4D:3&4; 5A:1-5; 6G: Points Sincerely, Mina L. Harkins, BSMT(ASCP), MBA NCQA AVP, Recognition Programs Policy and Resources

10 PCMH 2014 Prevalidation Step-by-Step Guide For Client Practices Practices that want to use autocredit for the PCMH Survey should do the following: Step 1: Obtain the NCQA-issued Prevalidation Summary Approval Table, NCQA Letter of Product Autocredit Approval as well as a Letter of Product Implementation from the vendor, indicating which prevalidated tool(s)/modules approved for autocredit have been implemented at the practice.* Step 2: Complete an application and enter into required agreements for the NCQA Recognition program. Step 3: Upload the vendor Prevalidation Summary Approval Table, the NCQA Letter of Product Autocredit Approval and Product Implementation Letter from the vendor into the Organizational Background section of the ISS Survey Tool. Step 4: In the Organization Background section under Prevalidation Tab of your ISS Survey tool, complete the site attestation under question 2B by checking the box. By doing so, you attest to the implementation and use of an NCQA Prevalidated health IT solution for associated autocredit points as specified in your attached NCQA Prevalidation Summary Approval Table. You will enter the name of the prevalidated health IT solution you are using in question 1. Step 5: Submit the Survey Tool. * The Letter of Product Implementation is drafted by the vendor on their organization s company letterhead and will include dates of implementation. All tools/modules with indicated version must be in place a minimum of 3 months prior to submission of the Survey Tool to NCQA for review. Page 10 of 61

11 PCMH 1: Patient-Centered Access Element 1A: Patient-Centered Appointment Access PCMH 1: Patient-Centered Access 10 points The practice provides access to team-based care for both routine and urgent needs of patients/families/caregivers at all times. Element 1A: Patient-Centered Appointment Access 4.5 points Element 1A is a Must Pass Element. Practices must earn a score of 50% or higher to pass this element. Element 1A also contains one Critical Factor: Factor 1. Factor 1 must be met for practices to receive a score on this element. The practice has a written process and defined standards for providing access to appointments, and regularly assesses its performance on: 1. Providing same-day appointments for routine and urgent care. Critical Factor 2. Providing routine and urgent-care appointments outside regular business hours. 3. Providing alternative types of clinical encounters. 4. Availability of appointments. 5. Monitoring no show rates. 6. Acting on identified opportunities to improve access. Scoring 100% 5-6 Factors (including Factor 1) 75% 3-4 Factors (including Factor 1) 50% 2 Factors (including Factor 1) 25% Factor 1 (not just any 1 factor) 0% 0 Factors (or does not meet Factor 1) Documentation and Workflow s Factor 1 - Critical Factor Documentation Dated, documented process for scheduling same-day routine and urgent care visits. Report with at least 5 days of data showing same-day access. Customers with a Practice Management (PM) system interface will schedule same-day appointment in their PM system. Customers without a Practice Management (PM) system interface will schedule same-day appointments using the Sevocity Scheduler. Desktop > Scheduler Page 11 of 61

12 PCMH 1: Patient-Centered Access Element 1A: Patient-Centered Appointment Access Factor 2 Documentation Dated, documented process for providing routine and urgent-care appointments outside regular business hours. Report showing at least five days of data or materials provided to patients. Schedule appointments during extended access hours in the PM system; customers without a PM system interface will use the Sevocity Scheduler to schedule appointments Factor 3 Documentation Dated, documented process for providing alternative types of clinical encounters. Report showing frequency of scheduled alternative encounter types in a recent 30-calendar day period. Document scheduled phone visit using the Telephone encounter type Utilize the Finalized Encounters report to capture Telephone encounters Utilize the Patient Portal to communicate clinical information with the patient during a scheduled time Factor 4 Documentation Dated, documented standards for timely appointment availability. Report with at least 5 days of data showing appointment wait times compared to practice defined standards including a policy for how the practice monitors appointment availability. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 5 Documentation Dated, documented process for monitoring appointment no show rates. Report showing rate of no shows from a recent 30-day period. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 6 Documentation Dated, documented process for acting on identified opportunities to improve access, using information gathered from Factors 1-5. Report showing the practice evaluated data on access, selected an opportunity and took action to improve access. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Page 12 of 61

13 PCMH 1: Patient-Centered Access Element 1B: 24/7 Access to Clinical Advice Element 1B: 24/7 Access to Clinical Advice 3.5 points Element 1B contains one Critical Factor: Factor 2. Factor 2 must be met for practices to receive a score higher than 25% on this element. The practice has a written process and defined standards for providing access to clinical advice and continuity of medical record information at all times, and regularly assesses its performance on: 1. Providing continuity of medical record information for care and advice when the office is closed. 2. Providing timely clinical advice by telephone. Critical Factor 3. Providing timely clinical advice using a secure, interactive electronic system. 4. Documenting clinical advice in patient records. Scoring 100% 4 Factors (including Factor 2) 75% 3 Factors (including Factor 2) 50% 2 Factors (including Factor 2) 25% 1 Factor (or does not meet Factor 2) 0% 0 Factors (or does not meet Factor 2) Documentation and Workflow s Factor 1 Documentation Dated, documented process for making patient clinical information available after hours for the purpose of providing care or medical advice. Security Administrators should ensure staff or other associated clinicians who need to access clinical information after hours have a Sevocity user login and password. Tools > Security Administration > Add User Security Administrators should ensure staff or other associated clinicians who need to access clinical information after hours have the appropriate user rights to access the information. Tools > Security Administration > Edit User Factor 2 - Critical Factor Documentation Dated, documented process for providing timely clinical advice after hours by telephone. Report with at least seven days of data showing after hours calls and response times. Utilize the Telephone encounter type to document after hours telephone encounters. Page 13 of 61

14 PCMH 1: Patient-Centered Access Element 1B: 24/7 Access to Clinical Advice Factor 3 Documentation Dated, documented process for providing timely clinical advice after hours using a secure, interactive electronic system. Report with at least seven days of data showing after hours s or electronic messages and response times. Utilize the Patient Portal to communicate to respond to patients requests for clinical advice. When replying to a Patient Portal message, select Store to Chart to save a copy of the original message and response to the patient s chart. Saved Patient Portal messages can be accessed by going to Chart > Past Encounters Factor 4 Documentation Dated, documented process for documenting clinical advice in the patient record. Three examples of clinical advice or report with percent of documented advice in the patient record. Provided examples must include one example of advice provided during office hours and one example of advice provided after hours. Document clinical advice provided by telephone in a Telephone encounter Use Store to Chart to save a copy of Patient Portal messages and responses to the patient s chart Access finalized encounters and saved Patient Portal messages by going to Chart > Past Encounters Page 14 of 61

15 PCMH 1: Patient-Centered Access Element 1C: Electronic Access Element 1C: Electronic Access 2 points The following information and services are provided to patients/families/caregivers, as specified, through a secure electronic system: 1. More than 50 percent of patients have online access to their health information within four business days of when the information is available to the practice. 2. More than 5 percent of patients view, and are provided the capability to download, their health information or transmit their health information to a third party. 3. Clinical summaries are provided within 1 business day(s) for more than 50 percent of office visits. 4. A secure message was sent by more than 5 percent of patients. 5. Patients have two-way communication with the practice. 6. Patients can request appointments, prescription refills, referrals and test results. Scoring 100% 5-6 Factors 75% 3-4 Factors 50% 2 Factors 25% 1 Factor 0% 0 Factors Documentation and Workflow s Factor 1 Documentation Report based on numerator and denominator for at least 3 months of data in the electronic system. Create Patient Portal accounts for patients to provide online access to their health information. Tools > Patient Portal > Add Patient/Alternate Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 1.C.1 Factor 2 Documentation Report based on numerator and denominator for at least 3 months of data in the electronic system. Ensure patients understand how to access and log in to the Patient Portal Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 1.C.2 Page 15 of 61

16 PCMH 1: Patient-Centered Access Element 1C: Electronic Access Factor 3 Documentation Report based on numerator and denominator for at least 3 months of data in the electronic system. Select the Clinical Summary provided to patient checkbox in the Plan/Disposition tab of the patient encounter. Encounter > Plan/Disposition/QM > Plan/Disposition Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 1.C.3 Factor 4 Documentation Report based on numerator and denominator for at least 3 months of data in the electronic system. Ensure patients understand how to access and use the Patient Portal Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 1.C.4 Factor 5 Documentation Screenshots showing the capability of the practice s system to provide two-way communication with the practice. Ensure Patient Portal is enabled for the practice Capture screenshot of the Patient Portal Inbox Using a test patient account, log in to the Patient Portal and capture a screenshot of the patient s ability to communicate with the practice. From Patient Portal home screen, go to My Messages > New Message Factor 6 Documentation Screenshots showing the capability of the practice s system for patients to request appointments, prescription refills, referrals and test results. Ensure Patient Portal is enabled for the practice Using a test patient account, log in to the Patient Portal and capture a screenshot of the patient s ability to request information from the practice. Screenshot must also include website URL. From Patient Portal home screen, go to My Messages > New Message Page 16 of 61

17 PCMH 2: Team-Based Care Element 2A: Continuity PCMH 2: Team-Based Care 12 points The practice provides continuity of care using culturally and linguistically appropriate, team-based approaches. Element 2A: Continuity 2 points The practice provides continuity of care for patients/families by: 1. Assisting patients/families to select a personal clinician and documenting the selection in practice records. 2. Monitoring the percentage of patient visits with selected clinician or team. 3. Having a process to orient new patients to the practice. 4. Collaborating with the patient/family to develop/implement a written care plan for patients transitioning from pediatric care to adult care. Scoring 100% 3-4 Factors 75% No scoring option 50% 2 Factors 25% 1 Factor 0% 0 Factors Documentation and Workflow s Factor 1 Documentation Dated, documented process for clinician selection. Example showing patient s choice of clinician on record. Document patient s choice of clinician in chart as a Professional Contact. To add or update a professional contact, go to Chart > Demographics > Professional Contacts > Update Factor 2 Documentation Report with at least five days of data showing patient encounters with the personal clinician. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Page 17 of 61

18 PCMH 2: Team-Based Care Element 2A: Continuity Factor 3 Documentation Dated, documented process outlining the process to orient patients to the practice. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 4 Documentation For pediatric practices: an example of a written transition care plan. For family medicine practices: a dated, documented process and materials for outreach. For internal medicine practices: a dated, documented process. Utilize the Plan/Disposition tab in a patient encounter to document transition plans and related information. Plan/Disposition/QM > Plan/Disposition Document referrals to another provider or setting of care in the Referrals tab, accessible from the patient chart and encounter. Chart > Referrals > Add or Encounter > Orders/Procedure > Orders/Referrals > Referrals > Add Page 18 of 61

19 PCMH 2: Team-Based Care Element 2B: Medical Home Responsibilities Element 2B: Medical Home Responsibilities 2.5 points The practice has a process for informing patient/families about the role of the medical home and gives patients/families materials that contain the following information: 1. The practice is responsible for coordinating patient care across multiple settings. 2. Instructions for obtaining care and clinical advice during office hours and when the office is closed. 3. The practice functions most effectively as a medical home if patients provide a complete medical history and information about care obtained outside the practice. 4. The care team provides access to evidence-based care, patient/family education and selfmanagement support. 5. The scope of services available within the practice including how behavioral health needs are addressed. 6. The practice provides equal access to all of their patients regardless of source of payment. 7. The practice gives uninsured patients information about obtaining coverage. 8. Instructions on transferring records to the practice, including a point of contact at the practice. Scoring 100% 7-8 Factors 75% 5-6 Factors 50% 3-4 Factors 25% 1-2 Factors 0% 0 Factors Documentation and Workflow s Factors 1-8 Documentation Dated, documented process for providing information and materials to patients/families/caregivers about the role and responsibilities of a medical home. Materials for patients/families/caregivers about the role and responsibilities of the medical home. Materials can include: brochures, letters, forms, written agreements, and Web materials. Utilize CLINIC or User Preferences to create customized letter templates. Tools > Preferences > CLINIC or [User] > Letter Templates > Begin Edit Utilize CLINIC Preferences to create customized patient handouts. Tools > Preferences > CLINIC > Patient Handouts > Begin Edit Utilize Sevocity s built-in patient education resources to find or print patient materials. Patient education is available at the patient chart and encounter level. Chart > Medications/Assessments > Assessments > Pt Ed button Chart > Medications/Assessments > Medications > PDR Page 19 of 61

20 PCMH 2: Team-Based Care Element 2B: Medical Home Responsibilities button Chart > Flowsheets/Labs > Scanned/E-Labs > Pt Ed button Encounter > Assessment > Pt Ed button Encounter > Medications > select medication name hyperlink Encounter > Flowsheets/Labs > Scanned/E-Labs > Pt Ed button Encounter > Immunizations > Add > VIS button Encounter > Plan/Disposition/QM > Plan/Disposition > Handouts or Patient Education Resources Page 20 of 61

21 PCMH 2: Team-Based Care Element 2C: Culturally and Linguistically Appropriate Services Element 2C: Culturally and Linguistically Appropriate Services 2.5 points The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by: 1. Assessing the diversity of its population. 2. Assessing the language needs of its population. 3. Providing interpretation or bilingual services to meet the language needs of its population. 4. Providing printed materials in the languages of its population. Scoring 100% 4 Factors 75% 3 Factors 50% 2 Factors 25% 1 Factor 0% 0 Factors Documentation and Workflow s Factor 1 Documentation Reporting showing the practice s assessment of the diversity of its patient population. Report should include race, ethnicity, and at least one other meaningful characteristic of diversity. Customers with a Practice Management (PM) system interface will document patient demographics in their PM system; customers without a PM system interface will document patient demographics in the Sevocity patient chart. Chart > Demographics > Patient Info > Update Run Patient List (Detailed) report to assess patient population race, ethnicity, and gender. Reports > Patient List (Detailed) Factor 2 Documentation Reporting showing the practice s assessment of the language composition of its patient population. Customers with a Practice Management (PM) system interface will document patient demographics in their PM system; customers without a PM system interface will document patient demographics in the Sevocity patient chart. Chart > Demographics > Patient Info > Update Run Patient List (Detailed) report to assess patient population preferred language. Reports > Patient List (Detailed) Page 21 of 61

22 PCMH 2: Team-Based Care Element 2C: Culturally and Linguistically Appropriate Services Factor 3 Documentation Dated, documented process for providing bilingual services, such as interpretive services or bilingual staff. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 4 Documentation Patient materials in languages other than English, screenshot showing system capabilities, link to online materials, or Web site offering patient materials in languages other than English. Utilize Sevocity s built-in patient education resources to find or print patient materials in languages other than English. VIS for immunizations are available in Spanish and Medline Plus resources offer patient materials in multiple languages. Patient education is available at the patient chart and encounter level. Chart > Medications/Assessments > Assessments > Pt Ed button Chart > Flowsheets/Labs > Scanned/E-Labs > Pt Ed button Encounter > Assessment > Pt Ed button Encounter > Flowsheets/Labs > Scanned/E-Labs > Pt Ed button Encounter > Immunizations > Add > VIS button Encounter > Plan/Disposition/QM > Plan/Disposition > Handouts or Patient Education Resources Page 22 of 61

23 PCMH 2: Team-Based Care Element 2D: The Practice Team Element 2D: The Practice Team 4 points Element 2D is a Must Pass Element. Practices must earn a score of 50% or higher to pass this element. Element 2D also contains one Critical Factor: Factor 3. Factor 3 must be met for practices to score higher than 25% on this element. The practice uses a team to provide a range of patient care services by: 1. Defining roles for clinical and nonclinical team members. 2. Identifying the team structure and the staff who lead and sustain team based care. 3. Holding scheduled patient care team meetings or a structured communication process focused on individual patient care. Critical Factor 4. Using standing orders for services. 5. Training and assigning members of the care team to coordinate care for individual patients. 6. Training and assigning members of the care team to support patients/families/caregivers in selfmanagement, self-efficacy and behavior change. 7. Training and assigning members of the care team to manage the patient population. 8. Holding scheduled team meeting to address practice functioning. 9. Involving care team staff in the practice s performance evaluation and quality improvement activities. 10. Involving patients/families/caregivers in quality improvement activities or on the practice s advisory council. Scoring 100% 10 Factors (including Factor 3) 75% 8-9 Factors (including Factor 3) 50% 5-7 Factors (including Factor 3) 25% 2-4 Factors (including Factor 3) 0% 0-1 Factors (or does not meet Factor 3) Documentation and Workflow s Factor 1 Documentation Dated staff position description or policies and procedures describing staff functions. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 2 Documentation Documented overview of the staffing structure for team-based care. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Page 23 of 61

24 PCMH 2: Team-Based Care Element 2D: The Practice Team Factor 3 - Critical Factor Documentation Documented process for structured communication between the clinician and other care team members, including frequency of communication. Minimum of three examples of meeting summaries, checklists, appointment notes, or chart notes proving that the practice follows its process. If staff communication process is documented as part of a patient encounter, finalized encounters can be accessed and printed from the patient chart. Chart > Past Encounters > [select encounter] > View or Print Factor 4 Documentation Minimum of one example of written standing orders. Utilize Health Guidelines to create standing orders. Tools > Preferences > CLINIC > Health Guidelines/Disease Management > Begin Edit Utilize encounter templates to create standing orders. Tools > Preferences > CLINIC or [User] > Encounter Templates > Begin Edit Factors 5-7 Documentation Documented description of the practice s staff training and training schedule or materials showing how staff has been trained in each area identified in these factors. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 8 Documentation Documented description of team meetings and the frequency of these meetings. Minimum of one example of meeting minutes, agendas, or staff memos. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 9 Documentation Dated, documented process for quality improvement activities, including a description of staff roles and involvement in the performance evaluation and improvement process. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 10 Documentation Dated, documented process demonstrating how the practice involves patients/families in its quality improvement efforts such as QI teams or an advisory council. Documentation can include meeting notes, meeting agendas, or committee structure. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Page 24 of 61

25 PCMH 3: Population Health Management Element 3A: Patient Information PCMH 3: Population Health Management 20 points The practice uses a comprehensive health assessment and evidence-based decision support based on complete patient information and clinical data to manage the health of the entire patient population. Element 3A: Patient Information 3 points The practice uses an electronic system to record patient information, including capturing information for factors 1-13 as structured (searchable) data for more than 80 percent of its patients: 1. Date of birth 2. Sex 3. Race 4. Ethnicity 5. Preferred language 6. Telephone numbers 7. address 8. Occupation (N/A for pediatric practices) 9. Dates of previous clinical visits 10. Legal guardian/health care proxy 11. Primary caregiver 12. Presence of advance directives (N/A for pediatric practices) 13. Health insurance information 14. Name and contact information of other health care professionals involved in patient s care Scoring 100% Factors 75% 8-9 Factors 50% 5-7 Factors 25% 3-4 Factors 0% 0-2 Factors Documentation and Workflow s Factors 1-5 Documentation Report with numerator and denominator with at least 3 months of data, showing the percentage of all patients for each populated data field. Customers with a Practice Management (PM) system interface will document patient demographics in their PM system; customers without a Page 25 of 61

26 PCMH 3: Population Health Management Element 3A: Patient Information PM system interface will document patient demographics in the Sevocity patient chart. Chart > Demographics > Patient Info > Update Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.A.1-5 Factors 6-8 Documentation Report with numerator and denominator with at least 3 months of data, showing the percentage of all patients for each populated data field. Factor 8 (Occupation) is NA for pediatric practices. Customers with a Practice Management (PM) system interface will document patient demographics in their PM system; customers without a PM system interface will document patient demographics in the Sevocity patient chart. Chart > Demographics > Patient Info > Update Practices should enter none in the field for patients who do not have an address or decline to provide one Run the Demographics report to capture patients with an address in their patient chart. Reports > Demographics Factor 9 Documentation Report with numerator and denominator with at least 3 months of data, showing the percentage of all patients for the populated data field. Run the Finalized Encounters report to capture dates of previous clinical visits. Report can be run by patient, location, user, date range and encounter type. Reports > Encounters > Finalized Encounters Factor 10 Documentation Report with numerator and denominator with at least 3 months of data, showing the percentage of all patients for the populated data field. Add a legal guardian/healthcare proxy to a patient s chart in the Patient Info tab in the Parent/Guardian 1 or Parent Guardian 2 field designations. Chart > Demographics > Patient Info > Update Factor 11 Documentation Report with numerator and denominator with at least 3 months of data, showing the percentage of all patients for the populated data field. Add a primary caregiver to a patient s chart in the Patient Info tab in the Other Contact field designation. Chart > Demographics > Patient Info > Update Factor 12 Documentation Report with numerator and denominator with at least 3 months of data, showing the percentage of all patients for the populated data field. Factor 12 is NA for pediatric practices. Page 26 of 61

27 PCMH 3: Population Health Management Element 3A: Patient Information Add advance directives to a patient s chart using Image/File Import, selecting Advanced Directives as the document type. Chart > Imported Documents > Scan or Import Factor 13 Documentation Report with numerator and denominator with at least 3 months of data, showing the percentage of all patients for the populated data field. Customers with a Practice Management (PM) system interface will document patient insurance in their PM system; customers without a PM system interface will document patient insurance in the Sevocity patient chart. Chart > Demographics > Insurance > Update Factor 14 Documentation Documented process for capturing information for other healthcare professionals involved in the patient s care Three examples demonstrating implementation of the process. This factor does not require the field to be searchable or structured data. Document name and contact information of other healthcare professionals involved in the patient s care as Professional Contacts. To add or update a professional contact, go to Chart > Demographics > Professional Contacts > Update Page 27 of 61

28 PCMH 3: Population Health Management Element 3B: Clinical Data Element 3B: Clinical Data 4 points The practice uses an electronic system with the functionality in Factors 6 and 7 and records the information in Factors 1-5 and 8-11 as structured (searchable) data: 1. An up-to-date problem list with current and active diagnoses for more than 80 percent of patients. 2. Allergies, including medication allergies and adverse reactions, for patients 3 years and older. 3. Blood pressure, with the date of update, for more than 80 percent of patients 3 years and older 4. Height/length for more than 80 percent of patients. 5. Weight for more than 80 percent of patients. 6. System calculates and displays BMI. 7. System plots and displays growth charts (length/height, weight, and head circumference) and BMI percentile (0-20 years) (N/A for adult practices). 8. Status of tobacco use for patients 13 years and older for more than 80 percent of patients. 9. List of prescription medications with date of updates for more than 80 percent of patients. 10. More than 20 percent of patients have family history recorded as structured data. 11. At least one electronic progress note created, edited and signed by an eligible professional for more than 30 percent of patients with at least one office visit. Scoring 100% 9-11 Factors 75% 7-8 Factors 50% 5-6 Factors 25% 3-4 Factors 0% 0-2 Factors Documentation and Workflow s Factor 1 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Maintain an up-to-date problem list in the Assessment tab of the patient encounter. Add, inactivate, change, or delete assessments as appropriate. Encounter > Assessment Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.1 Factor 2 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document patient allergies in Rcopia, accessed through the Allergies/Med Hx tab of the patient encounter. Encounter > Allergies/Med Hx > Manage Allergies/Med Hx > Manage Allergies Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.2 Page 28 of 61

29 PCMH 3: Population Health Management Element 3B: Clinical Data Factor 3 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document blood pressure in the Vitals tab of the patient encounter. Encounter > Vitals > Encounter > Add/Retake Vitals Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.3-6 Factor 4 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document height in the Vitals tab of the patient encounter. Encounter > Vitals > Encounter > Add/Retake Vitals Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.3-6 Factor 5 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document weight in the Vitals tab of the patient encounter. Encounter > Vitals > Encounter > Add/Retake Vitals Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.3-6 Factor 6 Documentation Screenshot demonstrating the system calculates and displays BMI. Capture screenshot of the Vitals tab displaying calculated BMI in a patient encounter or from the patient Chart Summary. Encounter > Vitals > Encounter or Chart > Summary Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.3-6 Factor 7 Documentation Screenshot demonstrating the system plots and displays growth charts and BMI percentile (0-20 years). Factor 12 is NA for adult practices. Capture screenshot of the system generated growth charts in the Vitals tab in a patient encounter or from the patient Chart. Encounter > Vitals > Encounter > Height Growth, Weight Growth, and BMI Growth or Chart > Immunizations/Growth Charts > Child > Height Growth, Weight Growth, and BMI Growth Page 29 of 61

30 PCMH 3: Population Health Management Element 3B: Clinical Data Factor 8 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document patient s smoking status in the Past History tab of the patient encounter using the MU Smoking Status structured data checkbox. Encounter > Past History > Structured > Social History > Smoking Status Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.8 Factor 9 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document patient medications in Rcopia, accessed through the Allergies/Med Hx tab or the Medications tab of the patient encounter. Encounter > Allergies/Med Hx > Manage Allergies/Med Hx > Manage Meds or Encounter > Medications > Manage/Prescribe Meds > Prescribe Perform and document a Medication Reconciliation when patient is received from another setting of care. Encounter > Medications > Medication Reconciliation Performed checkbox selected AND Encounter > Coding > Encounter Related to Transition of Care into Clinic checkbox selected Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.9 Factor 10 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document patient s family history in the Past History tab of the patient encounter using the MU Family History structured data checkboxes. Encounter > Past History > Structured > Family History > select MU Family History structured data checkboxes as appropriate Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.10 Factor 11 Documentation Report with at least 3 months of data, showing the percentage of all unique patients for each populated data field. Document and finalize patient encounters using an eligible encounter type in Sevocity. Chart > New Encounter > [select Encounter type] > OK Run the PCMH report to obtain data. Reports > PCMH (2014) > Factor 3.B.11 Page 30 of 61

31 PCMH 3: Population Health Management Element 3C: Comprehensive Health Assessment Element 3C: Comprehensive Health Assessment 4 points To understand the health risks and information needs of patients/families, the practice collects and regularly updates a comprehensive health assessment that includes: 1. Age- and gender appropriate immunizations and screenings. 2. Family/social/cultural characteristics. 3. Communication needs. 4. Medical history of patient and family. 5. Advance care planning (NA for pediatric practices). 6. Behaviors affecting health. 7. Mental health/substance use history of patient and family. 8. Developmental screening using a standardized tool (NA for practices with no pediatric patients). 9. Depression screening for adults and adolescents using a standardized tool. 10. Assessment of health literacy. Scoring 100% 8-10 Factors 75% 6-7 Factors 50% 4-5 Factors 25% 2-3 Factors 0% 0-1 Factors Documentation and Workflow s Factor 1 Documentation Report with at least 3 months of data, showing the unique patients who received an assessment for this factor. Utilize Health Guidelines to create or update immunization and screening alerts appropriate for the patient population. Tools > Preferences > CLINIC > Health Guidelines/Disease Management > Begin Edit Utilize the immunization schedule in Sevocity to document patient immunizations. Encounter > Immunizations > 0 to 2 or 2 to 18 or Adult Run the Health Maintenance Disease Management Reminder Lists report to monitor immunizations or screening due. Reports > Health Maintenance Disease Management Reminder Lists Run the Immunizations Due report to monitor immunizations due. Reports > Immunizations > Immunizations Due Factor 2 Documentation Report with at least 3 months of data, showing the unique patients who received an assessment for this factor. Page 31 of 61

32 PCMH 3: Population Health Management Element 3C: Comprehensive Health Assessment Document patient s family, social, and cultural characteristics in the Past History tab of the patient encounter. Encounter > Past History > Structured > Social History Factor 3 Documentation Report with at least 3 months of data, showing the unique patients who received an assessment for this factor. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 4 Documentation Report with at least 3 months of data, showing the unique patients who received an assessment for this factor. Document patient s medical history in the Past History tab of the patient encounter. Encounter > Past History > Structured > Medical History Document patient s family history in the Past History tab of the patient encounter. Encounter > Past History > Structured > Family History Factor 5 Documentation Report with at least 3 months of data, showing the unique patients who received an assessment for this factor. Factor 5 is NA for pediatric practices. Sevocity workflow not applicable. Please refer to the NCQA published PCMH Standards and Guidelines, 2014 for full details and examples. Factor 6 Documentation Report with at least 3 months of data, showing the unique patients who received an assessment for this factor. Document behaviors affecting patient s health in the Past History tab of the patient encounter. Encounter > Past History > Structured > Social History For pediatric patients, health concerns and nutrition and dental habits can be documented in the Pediatric tab of the patient encounter. Encounter > Pediatric > Structured Factor 7 Documentation Report with at least 3 months of data, showing the unique patients who received an assessment for this factor. Document patient s mental health history in the Past History tab of the patient encounter. Encounter > Past History > Structured > Medical History Page 32 of 61