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Details

PCMH Capabilities
1.0-14.10
188
Health Care
Not Applicable
03/18/2013
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Cards

Term
1.0
 Definition
Patient Provider Partnership
Term
2.0
 Definition
Patient Registry
Term
3.0
 Definition
Performance Reporting
Term
4.0
 Definition
Individual Care Management
Term
5.0
 Definition
Extended Access
Term
6.0
 Definition
Test Tracking
Term
8.0
 Definition
eRx
Term
9.0
 Definition
Preventive Services
Term
10.0
 Definition
Linkage to Community Services
Term
11.0
 Definition
Self Management
Term
12.0
 Definition
Web Portal
Term
13.0
 Definition
Coordination of Care
Term
14.0
 Definition
Specialist Referral Process
Term
1.1
 Definition
Communication process includes conversation with patient and member of the practice team. -Documentation of Partnership -Education Tools -All staff trained on PCMH -Tracking mechanism of patients w/partnership
Term
1.2
 Definition
Systematic process to inform patients about PCMH Systematic process to outreach to patients not visiting office regularly
Term
1.3
 Definition
10% patients have partnership
Term
1.4
 Definition
30% patients have partnership
Term
1.5
 Definition
50% patients have partnership
Term
1.6
 Definition
60% patients have partnership
Term
1.7
 Definition
80% patients have partnership
Term
1.8
 Definition
90% patients have partnership
Term
2.1
 Definition
Population-Diabetes
Term
2.2
 Definition
Functional -includes services received at other sites that are necessary to manage chronic disease (Labs, IPA, ER, UCC, Meds at least 4/5)
Term
2.3
 Definition
Functional- incorporates evidence based care guidelines (MQIC, HEDIS)
Term
2.4
 Definition
Functional- actively using at point of care
Term
2.5
 Definition
Functional- contains attributed practitioner (PCP identified in HIT)
Term
2.6
 Definition
Functional - used to identify gaps in care- communicated (mail, phone, email, portal) to pt
Term
2.7
 Definition
Functional- used to flag gaps in care for all pts in registry
Term
2.8
 Definition
Functional-contains demographics, key clinical indicators to chronic condition (HbA1c,LDL,BP)
Term
2.9
 Definition
Functional-fully electronic-direct feed of labs, admits, ED (must have 2.2)
Term
2.1
 Definition
Population- Asthma
Term
2.11
 Definition
Population- CAD(Coronary Artery Disease)
Term
2.12
 Definition
Population- CHF (Congestive Heart Failure)
Term
2.13
 Definition
Population- Includes 2 other chronic conditions
Term
2.14
 Definition
Functional- incorporates preventive services (mams, paps,imms, well visits) & outreach to engage them in practice.
Term
2.15
 Definition
Population- incorporates managed care plan patients (even those not visited practice)
Term
2.16
 Definition
Population- CKD (Chronic Kidney Disease)
Term
2.17
 Definition
Population- Pediatric Obesity (hgt, wgt, bmi, bp, labs, meds, & physical activity)
Term
2.18
 Definition
Population-Pediatric ADHD/ADD
Term
3.1
 Definition
Report tracking Diabetes patients
Term
3.2
 Definition
Reports at PO/Practice Unit and individual provider level
Term
3.3
 Definition
Reports include at least 2 other chronic conditions
Term
3.4
 Definition
Data in reports are validated and reconciled
Term
3.5
 Definition
Trend reports- PO aggregate data (1/4ly, yrly)
Term
3.6
 Definition
Report tracking Pediatric Obesity
Term
3.7
 Definition
Reports include ALL pts & preventive services
Term
3.8
 Definition
Reports include clinical info from other sources (labs, IP, ED, UC, Meds) to manage chronic care & preventive services (must have 2.2)
Term
3.9
 Definition
Reports include specialists services
Term
3.1
 Definition
Reports track Asthma
Term
3.11
 Definition
Reports track CAD
Term
3.12
 Definition
Reports track CHF
Term
3.13
 Definition
Reports track ADHD/ADD
Term
4.1
 Definition
All staff trained on PCMH, chronic care model and practice transformation (sign-in staff sheet)
Term
4.2
 Definition
ADVANCED CAP- Multidisciplinary team (include RN, DM educators, etc), regular team meetings, travel teams, ongoing communication with practice
Term
4.3
 Definition
Evidence based care guidelines are used at point of care, flags gaps in care, guidelines assist with appointment time booking
Term
4.4
 Definition
Patient survey re: office efficiency (Press Ganey OK)
Term
4.5
 Definition
Written action plans & goal setting patient specific for 1 chronic condition
Term
4.6
 Definition
Appointment reminder (upcoming appts) & tracking (no shows) for 1 chronic condition
Term
4.7
 Definition
System to ensure follow up for needed services for 1 chronic condition
Term
4.8
 Definition
Documented Process Required. Planned visit- proactive, team approach to manage care during visit for 1 condition. Identify team roles (who calls patients), encounter forms printed and on chart prior to visit, and team huddles
Term
4.9
 Definition
Group visit (2hrs, no more than 20 pts), must include 1 on 1 with MD
Term
4.1
 Definition
Medication review during visit
Term
4.11
 Definition
Action plans and self management offered to ALL chronic care /complex pt
Term
4.12
 Definition
Appointment tracking and reminder for ALL pts
Term
4.13
 Definition
System to ensure follow up for needed services for ALL patients
Term
4.14
 Definition
Documented Process Required. Planned visits for ALL pts w/ chronic conditions
Term
4.15
 Definition
Group visit for ALL patients
Term
4.16
 Definition
Advance Care Planning; conversation with patients and documentation.
Term
4.17
 Definition
Survivorship Plan; process in place once treatment is complete, documentation in chart, plan shared amongst patient's providers.
Term
4.18
 Definition
Palliative Care; assessment process in place and shared amongst all care providers (including specialist).
Term
5.1
 Definition
Access to 24 hr decision maker by phone w/feedback loop
Term
5.2
 Definition
On call has access to EMR/Registry and can update
Term
5.3
 Definition
8 after hours available (non ED - Urgent Care)
Term
5.4
 Definition
Patients educated on after hours care
Term
5.5
 Definition
12 after hours available
Term
5.6
 Definition
ADVANCED-Non ED after hours urgent care has access to EMR/Registry and documents DURING visit
Term
5.7
 Definition
Advanced access scheduling for 30% of daily appointments, written policy in place, patients are aware of policy.
Term
5.8
 Definition
50% schedule open
Term
5.9
 Definition
Interpreter service
Term
6.1
 Definition
Documented Process Required. Documented test tracking policy includes time frames for notification
Term
6.2
 Definition
Systematic approach to ensure time frames for pt notifications are met. Ensure test performed?
Term
6.3
 Definition
Update patient contact information
Term
6.4
 Definition
Mechanism in place to inform of normal test results
Term
6.5
 Definition
Mechanism to inform of abnormal results
Term
6.6
 Definition
Systematic approach to ensure follow up for abnormal results
Term
6.7
 Definition
Systematic approach for documentation of test tracking steps in medical record
Term
6.8
 Definition
Staff training on test tracking (yearly review?)
Term
6.9
 Definition
ADVANCED-CPOE with automated test tracking system.
Term
8.4
 Definition
Full e-Rx functionality by at least 1 or more PCPs.
Term
8.7
 Definition
Full e-Rx functionality by ALL PCPs.
Term
9.1
 Definition
Patient questionnaire about personal health behavior. i.e. patient check-in/demographic forms
Term
9.2
 Definition
Preventive care guidelines in use- MQIC/HEDIS
Term
9.3
 Definition
Outreach reminders- Birthday, annual physicals, imms, well visits
Term
9.4
 Definition
Inquires about outside health encounters- update patient chart history w/dates of services
Term
9.5
 Definition
Smoking cessation (material, support groups?)
Term
9.6
 Definition
Written standing order protocols for preventive services- imms, fecal occult blood, mam
Term
9.7
 Definition
Secondary prevention screening (Depression, Suicide, Mental Health, ADD/ADHD, Anorexia, etc)
Term
9.8
 Definition
Staff receives training, updates, MCIR data entry
Term
9.9
 Definition
Documented Process Required. Planned visits for preventative services
Term
10.1
 Definition
PO has conducted comprehensive review of resources available in geographic area
Term
10.2
 Definition
PO maintains a community resource database- case examples?
Term
10.3
 Definition
PO /PU has relationship w/community agency
Term
10.4
 Definition
All team members are educated and empowered to refer
Term
10.5
 Definition
Systematic approach to educate patients and families about resources and referrals (posters, etc)
Term
10.6
 Definition
Systematic referral process to community services - Appts made for patients? (dedicated staff member)
Term
10.7
 Definition
Systematic referral tracking (high risk)
Term
10.8
 Definition
Systematic process for follow up w/high risk patients regarding next steps
Term
11.1
 Definition
Member of clinical team or PO is educated on self management techniques. Must be in place before 11.2-11.7 No formal training needed (train the trainer okay), i.e. PTI training, Self mgmt toolkit. Regular, ongoing staff education regarding self mgmt techniques. Motivational interviewing, health literacy, teach backs, identification of obstacles
Term
11.2
 Definition
Self management support for 1 chronic condition- Travel team
Term
11.3
 Definition
Systematic follow up on goals, for 1 chronic condition- reach out between visits
Term
11.4
 Definition
Patient surveys for those involved in self management
Term
11.5
 Definition
Self management offered to all patients
Term
11.6
 Definition
Systematic follow up on goals, for all conditions- reach out between visits
Term
11.7
 Definition
Support and guidance offered to all patients working on self management goal
Term
11.8
 Definition
Stanford Certified Self Management Team member
Term
12.1
 Definition
Vendor options for purchase have been evaluated
Term
12.2
 Definition
PO assessed liability & safety issues for portal maintenance
Term
12.3
 Definition
Patients can request & schedule appointments electronically
Term
12.4
 Definition
Patients can log/graph self administered tests (glucose log)
Term
12.5
 Definition
Provider receives auto alert (flags) that potential health issue info has been logged
Term
12.6
 Definition
Patients can participate in E-visits
Term
12.7
 Definition
Automated care reminders (preventative services), education materials, resource links available electronically
Term
12.8
 Definition
Patient can create personal health record
Term
12.9
 Definition
Test results can be viewed on portal
Term
12.1
 Definition
Electronic Rx renewal
Term
12.11
 Definition
Patients can graph /analyze self administered tests for self management purposes
Term
12.12
 Definition
EMR available online
Term
13.1
 Definition
Notification of admit/discharge or other health encounter for 1 chronic condition. PCP getting info from other locations.
Term
13.2
 Definition
Information exchange process - transfer of care to other providers/facilities. PCP giving info to other locations.
Term
13.3
 Definition
Tracking process for care coordination for 1 chronic condition (Rounding form, EHR/EMR access-notification)
Term
13.4
 Definition
Process to flag for immediate attn any urgent follow up for 1 chronic condition (i.e. pt calls w/high glucose, wgt gain)
Term
13.5
 Definition
Written (policy) transition plans for patients leaving practice
Term
13.6
 Definition
Process for case management coordination BCN 800-392-2512 BCBSM 800-845-5982
Term
13.7
 Definition
Written procedure or guideline for care coordination process with clearly defined roles (i.e. Home care, rehab, acute hospital, SNF)
Term
13.8
 Definition
Care coordination in place for all patients with chronic conditions Must have 13.7 in place before 13.8 or 13.9
Term
13.9
 Definition
Care coordination in place for all patients
Term
14.1
 Definition
Documented procedures in place to guide specialist referral include time frames for appt & info exchange for high volume SCPs, & include info needed by SCP (reason for referral)
Term
14.2
 Definition
Documented procedures in place to guide specialist referral include time frames for appt & info exchange for other key SCPs who manage uncommon conditions (i.e. hand specialist)
Term
14.3
 Definition
Specialist directory is available
Term
14.4
 Definition
Specialist referral material supportive of process & individual pt needs (basic SCP info (name, location, off hrs), time frame for referral)
Term
14.5
 Definition
Appointments are made for patients
Term
14.6
 Definition
Electronic exchange of information is available to specialist- EHR
Term
14.7
 Definition
Referral tracking process - tickler file?
Term
14.8
 Definition
Staff trained on referral process
Term
14.9
 Definition
Patient satisfaction assessed and followed up for specialist care
Term
14.10
 Definition
Documented Procedure for physician-to-physician pre-consultation exchanges.
Term
15.1
 Definition
OSC has completed a plan to integrate patient registries of all the PCPs in the OSC
Term
15.2
 Definition
The patient registries of 50% of established PCP practices in the OSC are electronically linked/integrated
Term
15.3
 Definition
The patient registries of 95% of established PCP practices in the OSC are electronically linked and integrated
Term
15.4
 Definition
The patient registries of new practice units joining the OSC are electronically linked and integrated within 12 months of joining the OSC
Term
15.5
 Definition
All data in the integrated patient registry can be aggregated and analyzed at the OSC population level, as well as segmented by meaningful sub-units
Term
15.6
 Definition
Integrated patient registry includes all patients attributed to the OSC’s PCPs under BCBSM’s attribution methodology; registry is not limited to patients with chronic diseases
Term
15.7
 Definition
Integrated patient registry is all-payer, and includes all insured and uninsured patients in all OSC PCP practices
Term
15.8
 Definition
All data in the integrated patient registry is updated through automatic electronic feeds and incorporated into the registry at clinically relevant intervals, at least monthly
Term
15.9
 Definition
Integrated patient registry contains patient self-reported data on individual goal setting
Term
15.10
 Definition
Integrated patient registry contains imported structured patient Health Risk Appraisal data
Term
15.11
 Definition
Integrated patient registry contains patient self-reported data from systematic application of validated screening tools (e.g., PHQ22, PHQ9)
Term
15.12
 Definition
PO has a process in place to identify key care partners and sources for their data to be included in the integrated patient registry
Term
15.13
 Definition
information technology of those specialty types that most commonly collaborate with the OSC’s PCPs, and within those types, to those specialists who have executed a Primary Care- Specialist Agreement and have been nominated for an uplift
Term
15.14
 Definition
Integrated patient registry is electronically linked to the health information technology of those specialty types that most commonly collaborate with the OSC’s PCPs, and within those types, to those specialists who have executed a Primary Care- Specialist Agreement but have NOT been nominated for an uplift
Term
15.15
 Definition
Integrated patient registry is electronically linked to the health information technology of key specialists (across all specialty types) engaged in caring for at least 95% of the OSC’s patient population
Term
15.16
 Definition
Integrated patient registry is electronically linked to the health information technology of key hospitals engaged in caring for the OSC’s patient population
Term
15.17
 Definition
Integrated patient registry is electronically linked to the health information technology of key laboratories engaged in caring for the OSC’s patient population
Term
15.18
 Definition
Integrated patient registry is electronically lined to the health information technology of key electronic prescribing systems or PBMs that are used in caring for the OSC’s patient population
Term
15.19
 Definition
Integrated patient registry electronically captures relevant health information from key community agencies and public institutions engaged in caring for the OSC’s patient population, including but not limited to food banks, shelters, counseling centers, youth development centers
Term
15.20
 Definition
Integrated patient registry is electronically linked to the health information technology of key non-hospital facilities engaged in caring for the OSC’s patient population
Term
15.21
 Definition
Integrated patient registry incorporates basic patient information that will allow the OSC to identify and address disparities in care
Term
15.22
 Definition
Integrated patient registry incorporates advanced patient information that will allow the OSC to identify and address disparities in care
Term
15.23
 Definition
Integrated patient registry electronically exchanges key clinical information among providers of care and patient authorized entities
Term
15.24
 Definition
Integrated patient registry incorporates claims data from health plans and non-OSC providers
Term
16.1
 Definition
OSC performance measures are reliable and actionable and are used for the development of internal quality improvement efforts
Term
16.2
 Definition
OSC performance measures are aligned with nationally or regionally-recognized performance measures
Term
16.3
 Definition
OSC performance reports address a range of population segments and incorporate risk stratification and other methods to identify populations most in need of intervention and with the greatest opportunity for improvement
Term
16.4
 Definition
OSC performance reports measure transitions across care settings and over time
Term
16.5
 Definition
OSC performance measures address patient experience
Term
16.6
 Definition
OSC performance reports should include measures that incorporate health plan claims data
Term
17.1
 Definition
Patient-Provider Partnership: a. OSC ensures that a system is in place to track implementation of patient- provider partnership capabilities in member PCP offices
Term
17.2
 Definition
Individual Care Management
Term
17.3
 Definition
Extended Access
Term
17.4
 Definition
Test Results Tracking & Follow-up
Term
17.5
 Definition
Preventive Services
Term
17.6
 Definition
Linkage to Community Services
Term
17.7
 Definition
Self-Management Support
Term
17.8
 Definition
Patient Web Portal
Term
17.9
 Definition
Coordination of Care
Term
17.10
 Definition
Specialist Referral Process
Term
17.11
 Definition
Access to Specialists
Term
17.12
 Definition
Access to Behavior Specialists
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