TCPI NCQA PCMH (for Primary Care*) High-level Crosswalk Document* (v )

TCPI NCQA PCMH (for Primary Care*) High-level Crosswalk Document* (v1. 6.13.16) *Note: Accreditation of Specialist through NCQA uses different Standards/ program requirements than Primary Care NCQA PCMH Background information: Eligibility for NCQA PCMH Recognition Physicians, NPs & PAs who practice in internal medicine, family medicine, or pediatrics and with the intention of serving as the personal PCP for their patients All eligible clinicians at practice site must be included in the PCMH Application If you have 3 or more practice sites Obtain multi-site approval first PCMH Standards: 1. Patient-Centered Access 2. Team-Based Care 3. Population Health Management 4. Care Management and Support 5. Care Coordination and Care Transitions 6. Performance Measurement and Quality Improvement NCQA Recognition Criteria and Scoring: 6 Standards 28 Elements 152 Factors Recognition Level Points Must Pass Elements Level 3 85-100 6 of 6 Level 2 60-84 6 of 6 Level 1 35-59 6 of 6 Not recognized 0-34 <6 1

NCQA s PCMH 2014 Standards **Must Pass Elements Minimum Documentation and Reporting Period + Stage 2 Core Meaningful Use Requirement ++ Stage 2 Menu Meaningful Use Requirement +++ Meaningful Use Requirement (prior to 2015-2017 Modified MU Rule Unsure of NCQA position on Rule change) Standard 1: Patient-Centered Access 1. A. Patient-Centered Appointment Access *MUST PASS* 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 TCPI Milestones (that contribute to NCQA Standard) - Language extracted from CMS change package that directly supports PCMH Standards, Elements and Factors. - The change package includes more specific language that better aligns with NCQA PCMH 1.7.1 Provide 24/7 access to care team: Expanded hours in evenings and weekends with access to the patient medical record Use alternatives to increase access to care-team and provider, such as e-visits, phone visits, group visits, home visits and alternate locations Provide same-day or next-day access to a consistent provider or care team when needed for urgent care or transition management 1.7.2 Meet patient scheduling needs Measure and balance supply and demand of patient access issues and then expand or modify hours as needed 1.7.4 Mitigate access barriers For patients with frequent no shows, ask patients about reasons and develop potential solutions to address them 2.4.1 Innovate for access Use telemedicine visits for patients in rural areas or for specialty consultations Use web-based video technology (e.g., Skype) for homebound patients Primary Driver 3 Sustainable Business Operations 3.4.3 Maximize provider value Develop walk-in care model Adjust schedules to account for no shows 2

1. B. 24/7 Access to Clinical Advice 1. Providing continuity of medical record information for care and advice when 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 1. C. Electronic Access + 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 for more than 50 percent of office visits 4. A secure message was sent to more than 5 percent of patients 5. Patients have a two-way communication with the practice 6. Patients can request appointments, prescription refills, referrals and test results Standard 2: Team-Based Care 2. A. Continuity 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 transitioning from pediatric care to adult care 1.7.1 Provide 24/7 access to care team: Provide 24/7 access to provider or care team for advice about urgent and emergent care Provide care team with access to medical record after hours Ensure providers who are cross-covering have access to medical record 2.4.1 Innovate for Access Use secure email visits Use patient portals to avoid unnecessary visits to provider and answer questions by appropriate care team member 2.4.4 Use technology for partnerships Encourage use of a patient portal 1.7.1 Provide 24/7 access to care team: Maintain a patient portal and encourage its use by patients and families 1.1.3 Collaborate with patients and families Ensure patient leaves office with plan of care in hand 2.4.1 Innovate for Access Use patient portals to avoid unnecessary visits to provider and answer questions by appropriate care team member Use portal or texting to provide electronic reminders 2.4.4 Use technology for partnerships Encourage use of a patient portal Introduce patients to the practice s capacity to communicate with them via electronic means Involve patients and family advisors in introducing the patient portal and showing patients how to use it 1.1.1 Respect Values and Preferences Always ask patients about their preferences; don t assume 1.2.3 Optimize continuity Measure continuity between patient and provider and/or care team Use scheduling strategies that optimize continuity while accounting for needs for urgent access 1.3.1 Assign to panels Review and update panel assignments on a regular basis 3

2. B. Medical Home Responsibilities 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 self-management support. 5. The scope of services available within the practice include 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 2. C. Culturally and Linguistically Appropriate Services 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 1.1.2 Listen to patient and Family voice Communicate to patients the changes being implemented by the practice. Educate patients and community on what they should expect and look for in a physician. Currently, it is very difficult to know who the excellent providers are. 1.1.3- Collaborate with Patients and Families Educate patients and families on health care transformation so they can be active, informed change agents. Use appropriate language, simple language, and pictures Primary Driver 3 Sustainable Business Operations 3.1.6 Ensure Business Accuracy Assist families in Medicaid enrollment 1.1.1 Respect Values and Preferences Always ask patients about their preferences; don t assume Develop a template form that can be used for patients and families to identif y preferences while waiting 1.1.4-Be aware of language and culture Maintain multi-lingual staff; contract for translation services where staff cannot be used Use multi-lingual written and oral communication Provide self-management materials at an appropriate literacy level and in an appropriate language Be aware of patient s sexual orientation 4

2. D. The Practice Team *Must Pass* 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 self-management, self-efficacy and behavior changes 7. Training and assigning members of the care team to manage the patient population 8. Holding scheduled meetings 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 1.1.2 Listen to patient and family voice Implement a patient and family advisory group 1.1.3-Collaborate with Patients and families Train staff in motivational interviewing approaches Train staff in self-management goal setting 1.2.1 Enhance Teams Use multidisciplinary huddles for care planning each morning or at the start of each session Use huddles to make just in time adjustments to schedule or staffing to accommodate unexpected situations Define roles and distribute tasks among care team members, consistent with the skills, abilities and credentials of team members to better meet patient needs 1.2.2 Clarify team roles Inventory the work to be done prior to a patient visit, during the visit, and after the visit and determine who in the organization can do each part of the work by matching their training and skills sets 2.1.3 Create a shared vision At the care team and department level, use regular meetings to take the vision and break it down into discrete parts that people can relate to their own job 2.2.1 Use an organized QI approach Use an interdisciplinary staff committee to lead change and improvement within the organization Establish a QI committee that includes staff from clinical and administrative settings as well as finance 2.2.2 Build QI Capacity Train all staff in how to act on data: how to interpret graphs and where to go and what do with the information to continue, accelerate or initiate improvement 2.2.3 Empower staff Use the knowledge of frontline staff to shape QI efforts 2.4.5 Drive efficiency through technology Create care teams and assign staff to manage incoming and outgoing messages Primary Driver 3 Sustainable Business Operations 3.1.5 Drive performance excellence Consider hiring additional staff to support transformation efforts such as a care transitions manager, social worker, or other ancillary service providers Invest in staff education 3.2.3 Cultivate Joy in work Emphasize staff development and training 5

Standard 3: Population Health Management 3. A. Patient Information + 1. Date of Birth 2. Gender 3. Race 4. Ethnicity 5. Preferred Language 6. Telephone numbers 7. E-mail address 8. Occupation (NA for pediatric practices) 9. Dates of previous clinical visits 10. Legal guardian/health care proxy 11. Primary caregiver 12. Presence of advance directives (NA for pediatric practices) 13. Health insurance information 14. Name and contact information of other health care professionals involved in patient s care 3. B. Clinical Data +, ++ 1. An up-to-date problem list with current and active diagnoses for more than 80% of patients 2. Allergies, including medication allergies and adverse reactions, for more than 80% of patients 3. Blood pressure, with the date of update, for more than 80% of patients 3 years and older + 4. Height/length for more than 80% of patients 5. Weight for more than 80% 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) (NA for adult practices) 8. Status of tobacco use for patients 13 years and older for more than 80% of patients 9. List of prescription medications with date of updates for more than 80% of patients 10. More than 20% 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% of patients with at least one office visit 1.1.1 Respect values and preferences Develop a template form that can be used for patients and families to identify preferences while waiting Use a check-in approach to query patients about specific aspects of care delivery to determine their thoughts and preferences 2.4.3 Use technology supporting evidence Use reports available from the EHR to support QI initiatives 2.4.5 Drive efficiency through technology Use the computer to do routine or repetitive work (querying data, assigning reminders, etc.) and use staff for interacting with patients and families 2.4.3 Use technology supporting evidence Use reports available from the EHR to support QI initiatives 2.4.5 Drive efficiency through technology Use the computer to do routine or repetitive work (querying data, assigning reminders, etc.) and use staff for interacting with patients and families 6

3. C. Comprehensive Health Assessment 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 3. D. Use Data for Population Management + *MUST PASS* 1. At least two different preventive care services 2. At least two different immunizations 3. At least three different chronic or acute care services 4. Patients not recently seen by the practice 5. Medication monitoring or alert 1.4.1 Be aware of language and culture Assess health literacy for all patients 1.6.1 Consider the whole person Include use of non-clinical staff to provide screening and assessment of behavioral health care needs Primary Driver 1 Person and Family-Centered Care Design 1.3.4 Develop registries Dedicate resources to population health management 1.6.2 PLAN care Use panel support tools (e.g., registry functionality) to identify services that are due for the patient Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due 2.3.1 Use Data Transparently Identify a set of EHR-derived clinical quality and utilization measures that are meaningful to the practice team 2.4.2 SharenInformation through technology Transfer results to a flow sheet so they can be queried Enter data into discrete data fields whenever available to maximize potential of business intelligence tools 2.4.3 Use technology supporting evidence Produce and use gap reports from the EHR Build reminders and alerts into the EHR Build disease and preventive registries to manage populations 2.4.4 Use technology for partnerships Use text reminders and care coordination messages for outreach 7

3. E. Implement Evidence-Decision Support + 1. A mental health or substance use disorder (Critical Factor) 2. A chronic medical condition 3. An acute condition 4. A condition related to unhealthy behaviors 5. Well child or adult care 6. Overuse/appropriateness issues Standard 4: Case Management and Support 4. A. Identify High-Risk Patients for Care Management 1. Behavioral health conditions 2. High cost/high utilization 3. Poorly controlled or complex conditions 4. Social determinants of health 5. Referral by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver 6. The practice monitors the percentage of the total patient population identified through its process and criteria (Critical Factor) 1.1.3 Collaborate with patients and families Use evidence-based decision aids to provide information about risks and benefits of care options in preference-sensitive conditions 1.6.1 Consider the whole person Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment 1.6.3 Implement evidence based protocols Develop evidence-based protocols in house or use those externally available Document protocols through flow sheets, process maps, care maps, swim lanes or other visual depiction Use protocols to guide communication with patients and families after a patient safety event Embed protocols in the EHR 1.6.4 Decrease care gaps Use clinical decision support aids such as ACR Select 1.1.3 Collaborate with patients and famiies Use evidence-based decision aids to provide information about risks and benefits of care options in preference-sensitive conditions 1.3.3 Stratify risk Identify a risk stratification approach and use it consistently Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts Use panel management and registry capabilities to support management of patients at low and intermediate risk Use risk level to identify best provider for the patient Use social determinants of health in risk-stratification models 1.5.1 Manage care transitions Assign responsibility for care management of individuals at high risk for emergency department visits or hospital readmission 8

4. B. Care Planning and Self-Care Support *MUST PASS* 1. Incorporates patient references and functional/lifestyle goals 2. Identifies treatment goals 3. Assesses and addresses potential barriers to meeting goals 4. Includes a self-management plan 5. Is provided in writing to the patient/family/caregiver 1.1.3 Collaborate with patients and families Create a shared care plan for every patient Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the Electronic Health Record (EHR) Incorporate evidence-based techniques to promote self- management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How s My Health) Provide coaching between visits with follow-up on care plan and goals Ensure patient leaves office with plan of care in hand 1.2.3 Optimize continuity Use a shared care plan to ensure continuity of management between within the practice and with consultants (for high risk patients) 1.3.3 Stratify risk Implement a standard approach to documenting care plans Engage patients at highest risk in ongoing development and refinement of their care management plan, to include integration of patient goals, values and priorities Identify ways to graduate patients from care management when goals are met as appropriate Deliver care plan with patient and family 1.5.5 Manage Medication reconciliation Develop a medication action plan for high-risk patients 1.6.2 Plan care Provide patients annually with an opportunity for development and/or adjustment of an individualized plan of care, including health risk appraisal; gender, age and conditionspecific preventive care services; plan of care for chronic conditions; and advance care planning 9

4. C. Medication Management + 1. Reviews and reconciles medications with patients received from care transitions (Critical Factor) 2. Reviews and reconciles medications with patients/families for more than 80% of care transitions 3. Provides information about new prescriptions to more than 80% of patients/families/caregivers 4. Assesses understanding of medications for more than 50% of patients/families/caregivers, and dates the assessment 5. Assesses response to medications and barriers to adherence for more than 50% of patients, and dates the assessment 6. Documents over-the-counter medications, herbal therapies and supplements for more than 50% of patients, and dates updates. 4. D. Use Electronic Prescribing + 1. More than 50% of eligible prescriptions written by the practice are compared to drug formularies and electronically sent to pharmacies 2. Enters electronic medication orders in the medical record for more than 60% of medications 3. Performs patient-specific checks for drug-drug and drugallergy interactions 4. Alerts prescribers to generic alternatives 1.5.5 Manage medication reconciliation Reconcile medications at each visit Provide follow up on medication use after hospital discharge Conduct medication reconciliation at every encounter Coordinate medications across transitions of care settings and providers Conduct periodic, structured medication reviews Develop a medication action plan for high-risk patients Provide collaborative drug therapy management for selected conditions or medications Provide support for medication self-management Always think about health literacy when talking about prescriptions 2.4.2 Share information through technology E-prescribe where possible 10

4. E. Support Self-Care and Shared Decision Making + 1. Uses an EHR to identify patient-specific education resources and provide them to more than 10% of patients 2. Provides educational materials and resources to patients 3. Provides self-management tools to record self-care results 4. Adopts shared decision making aids 5. Offers or refers patients to structured health education programs, such as group classes and peer support 6. Maintains a current resource list of five topics or key community service areas or importance to the patient population including services offered outside the practice and its affiliates 7. Assesses usefulness of identified community resources 1.1.3 Collaborate with patients and families Incorporate evidence-based techniques to promote self- management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing Use tools to assist patients in assessing their need for support for self-management (e.g., the Patient Activation Measure or How s My Health) Train staff in self-management goal setting Provide peer-led support for self-management Provide group visits for common chronic conditions (e.g., diabetes) Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community Train staff in self-management goal setting 1.1.4 Be aware of language and culture Provide self-management materials at an appropriate literacy level and in an appropriate language 1.4.2 Community collaboration Work with community agencies to enhance services available to patients Create a document summarizing best community resources that patients and family can use as reference 1.5.4 Ensure quality referrals Provide a guide to available community resources 11

Standard 5: Care Coordination and Care Transitions 5. A. Test Tracking and Follow-Up +, ++ 1. Track lab tests until results are available, flagging and following up on overdue results (Critical Factor) 2. Track imaging tests until results are available, flagging and following up on overdue results (Critical Factor) 3. Flags abnormal lab results, bringing them to the attention of the clinician 4. Flags abnormal imaging results, bringing them to the attention of the clinician 5. Notifies patients/families of normal and abnormal lab and imaging test results 6. Follows up with the inpatient facility about newborn hearing and newborn blood-spot screening (NA for adults) 7. More than 30% of laboratory orders are electronically recorded in the patient record 8. More than 30% of radiology orders are electronically recorded in the patient record 9. Electronically incorporates more than 55% of all clinical lab test results into structured fields in medical record 10. More than 10% of scans and tests that result in an image are accessible electronically 1.2.3 Optimize continuiuty Electronically share information with care providers outside the practice so that information or tests are not duplicated 2.4.2 Share information through technology Use standard interfaces for lab services and connect with most frequently used labs Transfer results to a flow sheet so they can be queried 2.4.3 Use technology supporting evidence Develop a EHR solution to computerize the reporting of patient critical results 12

5. B. Referral Tracking and Follow-Up + *Must Pass* 1. Considers available performance information on consultants/specialists when making referral recommendations 2. Maintains formal and informal agreements with a subset of specialist based on established criteria 3. Maintains agreements with behavioral healthcare providers 4. Integrates behavioral healthcare providers within the practice site 5. Gives the consultant or specialist the clinical question, the required timing and the type of referral 6. Gives the consultant or specialist pertinent demographic and clinical data, including test results and the current care plan 7. Has the capacity for electronic exchange of key clinical information+ and provides an electronic summary of care record to anything provider for more than 50% of referrals 8. Tracks referrals until the consultant or specialists report is available, flagging and following up on overdue reports (Critical Factor) 9. Documents co-management arrangements in the patient s medical record 10. Ask patients/families about self-referrals and requesting reports form clinicians 5. C. Coordinate Care Transitions + 1. Proactively identifies patients with unplanned hospital admissions and emergency department visits 2. Shares clinical information with admitting hospitals and emergency departments 3. Consistently obtains patient discharge summaries from the hospital and other facilities 4. Proactively contacts patients/families for appropriate follow-up care within an appropriate period following a hospital admission or emergency department visit 5. Exchanges patient information with the hospital during a patient s hospitalization 6. Obtains proper consent for release of information and had a process for secure exchange of information and for coordination of care with community partners 7. Exchanges key clinical information with facilities and provides an electronic summary-of-care record to another facility for more than 50% of patient transitions of care 1.5.4 Ensure quality referrals Vet all potential referral providers and agencies Leverage personal relationships to cultivate referral opportunities Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information Maintain a referral tracking system to assure loop closure 1.6.1 Consider the whole person Develop formal referral relationships with mental health and substance abuse services in the community 2.4.2 Share information through technology Use direct secure messaging to share referral information and notifications to/from hospitals and emergency departments Develop information exchange processes and care compacts with other service providers with which the practice shares patients Use standard documents created by the EHR to routinely share information (e.g., medications, problem, allergies, goals of care, etc.) at time of referral and transition between settings of care Standardize referral templates so appropriate information is shared Primary Driver 3 Sustainable Business Operations 3.1.4 Benefit from performance patments Join a clinically integrated network 1.5.1 Manage care transitions Assign responsibility for care management of individuals at high risk for emergency department visits or hospital readmission Follow up after every hospital discharge and ED visit with a phone call, home or office visit Assure patients can get access to their care team when they need it to support reduction in emergency department use Partner with community or hospital-based transitional care services Routine and timely follow-up to hospitalizations Routine and timely follow-up to emergency department visits Establish a mutual understanding of the information that should be shared when care is transferred or shared among providers Ensure that useful information is shared with patients and families at every care transition 2.4.2 Share information through technology Use direct secure messaging to share referral information and notifications to/from hospitals and emergency departments 13

Standard 6: Performance Measurement and Quality Improvement 6. A. Measure Clinical Quality Performance 1. At least two immunization measures 1.3.4 Develop rregistries 2. At least two other preventive care measures Report quality, cost, and utilization metrics for the entire population as well as 3. At least three chronic acute care clinical measures subpopulations 4. Performance data stratified for vulnerable populations (to assess disparities in care) 2.3.1 Use data transparently Define measures that the practice will monitor, relate these to strategic aims, and use them to drive performance Monitor measures as frequently as possible and share metrics with all staff Identify a set of EHR-derived clinical quality and utilization measures that are meaningful to the practice team Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or provider 6. B. Measure Resource Use and Care Coordination 1. At least two measures related to care coordination 2. At least two utilization measures affecting health care costs 6. C. Measure Patient/Family Experience 1. The practice conducts a survey (using any instrument) to evaluate patient/family experiences on at least three of the following categories: Access Communication Coordination Whole-person care/self-management support 2. The practice uses the PCMH version of the CAHPS Clinician & Group Survey Tool 3. The practice obtains feedback on experiences of vulnerable patient groups 4. The practice obtains feedback from patients/families through qualitative means (panel) 1.3.4 Develop rregistries Report quality, cost, and utilization metrics for the entire population as well as subpopulations 2.3.1Use Data transparently Identify a set of EHR-derived clinical quality and utilization measures that are meaningful to the practice team Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or provider (panel) 1.1.2 Listen to patient and family voice Include a patient on the organization s board Implement a patient and family advisory group Regularly survey patients and families Invite patients to operational meetings Include patients and families in all quality improvement (QI) initiatives Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms Run focus groups to obtain patient and family feedback Use real-time electronic systems for capturing patient feedback 14

6. D. Implement Continuous Quality Improvement *MUST PASS* 1. Set goals and analyze at least three clinical quality measures from Element A 2. Act to improve at least three clinical quality measures from Element A 3. Set goals and analyze at least one measure from Element B 4. Act to improve at least one measure from Element B 5. Set goals and analyze at least one patient experience from Element C 6. Act to improve at least one patient experience measure form Element C 7. Set goals and address at least one identified disparity in care/service for identified vulnerable populations 6. E. Demonstrate Continuous Quality Improvement 1. Measuring the effectiveness of the actions it takes to improve the measures selected in Element D 2. Achieving improved performance on at least two clinical quality measures 3. Achieving improved performance on one utilization of care coordination measure 4. Achieving improved performance on at least one patient experience measure 2.2.1 Use an organized QI approach Define specific timelines for improvement with identified opportunities 2.2.2 Build QI capacity Track progress toward goals at each site (if applicable) and individual provider level 2.3.1 Use data transparently Define measures that the practice will monitor, relate these to strategic aims, and use them to drive performance Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or provider (panel) Use relevant data sources to create benchmarks and goals for performance at the practice level and panel level Include patient satisfaction data and patient feedback about high performers in regular reporting to staff and community Primary Driver 3 Sustainable Business Operations 3.1.6 Ensure Business Accuracy Use dashboards and metrics to identify QI opportunities Same as above (6D). 15

6. F. Report Performance 1. Individual clinician performance results with the practice 2. Practice-level performance results with the practice 3. Individual clinician or practice-level performance results publicly 4. Individual clinician or practice-level performance results with patients 1.1.2Listen to patient and family voice Communicate to patients the changes being implemented by the practice. Transparency in data, (quality, complications, readmissions, etc. should be publicly available) 1.4.5 Be transparent Publish performance results in a newsletter or on website 2.1.1 Commit leadership Openly share the transformation vision and progress toward achieving goals with staff, board and community Communicate openly and frequently about organizational aims and performance both within and outside the organization 2.2.2 Build QI capacity Track progress toward goals at each site (if applicable) and individual provider level Promote transparency and accelerate improvement by sharing practice level and panel level quality of care, patient experience and utilization data with staff Promote transparency and engage patients and families by sharing practice level quality of care, patient experience and utilization data with patients and families 2.3.1Use data transparently Include metrics on organization s website Create meaningful, useful data displays for front-line staff evaluation of progress Regularly review measures of quality, utilization, patient satisfaction and other measures that may be useful at the practice level and at the level of the care team or provider (panel) 2.3.2Set goals and benchmarks Share goals broadly throughout the organization Primary Driver 3 Sustainable Business Operations: 3.1.2 Use patient as customer feedback Capitalize on positive patient feedback by highlighting data in external publications and website 3.2.3 Cultivate Joy in work Post quality and data gains 16

6. G. Use Certified EHR Technology +, ++, +++ 1. The practice use an EHR system (or modules) that has been certified and issued a CMS certification ID 2. The practice conducts a security risk analysis of its EHR system (or modules), implements security updates as necessary and corrects identified security deficiencies 3. The practice demonstrates the capability to submit electronic syndromic surveillance data to public health agencies electronically 4. The practice demonstrates the capability to identify and report specific cancer cases to a public health central cancer registry electronically 5. The practice demonstrates the capability to identify and report specific cases to a specialized registry (other than a cancer registry) electronically 6. The practice reports clinical quality measures to Medicare or Medicaid agency, as required for Meaningful Use 7. The practice demonstrates the capability to submit data to immunization registries or immunization information systems electronically 8. The practice has access to a health information exchange 9. The practice has bidirectional exchange with a health information exchanged 10. The practice generates lists of patients, and based on their preferred method of communication, proactively reminds more than 10% of patients/families/caregivers about needed preventive/follow-up care 1.6.2 plan care Use reminders and outreach (e.g., phone calls, emails, postcards, patient portals and community health workers where available) to alert and educate patients about services due 2.4.1 Innovate for access Use portal or texting to provide electronic reminders 2.4.2 Share information through technology Use an EHR certified by the Office of the National Coordinator Connect to local health information exchanges, if available Connect the EHR with state immunization and condition-specific registries to allow two-way sharing of information 17