AC07 - Has a secure electronic system for patient to request appointments, prescription Elective Evidence of implementation Yes refills, referrals, and test results AC08 - Has a secure electronic system for Documented process AND Yes Elective two-way communication to provide timely Report Yes clinical advice AC09 - Uses information about the population served by the practice to assess equity of Elective Evidence of implementation No access AC10 - Helps patients/caregivers select or Core Documented process Yes change a personal clinician AC11 - Sets goals and monitors the percentage of patient visits with the selected Core Report No clinician or team AC12 - Provides continuity of medical record information for care and advice when the Elective Documented process Yes office is closed Documented process AND Yes AC13 - Reviews and actively manages panel Elective size Report No AC14 - Reviews and reconciles panels based Documented process AND Yes Elective on health plan or other outside patient Evidence of implementation No assignments Core vs. Criterion for Care Management (CM) Evidence Type Elective Eligible Protocol for identifying patients CM01 - Considers 3 out of 5 NCQA measures Yes for care management OR when identifying patients who may benefit Core from care management CM03 Yes CM02 - Monitors the percentage of the total patient population identified through its Core Report No process and criteria CM03 - Applies a comprehensive Elective Report Yes process for patient Report OR No CM04 - Establishes a care plan for patients Core [Record Review Workbook and No identified for care management Patient examples] No Report OR No CM05 - Provides a written care plan to the patient/family/caregiver for patients Core [Record Review Workbook and No identified for care management Patient examples] No Report OR No CM06 - Documents patient preference and Elective functional/lifestyle goals in individual care [Record Review Workbook and No plans Patient examples] No Report OR No Elective CM07 Identify and discuss potential barriers – [Record Review Workbook and No to meeting goals in individual care plans Patient examples] No
AC07 - Has a secure electronic system for patient to request appointments, prescription refills, referrals, and test results Elective Evidence of implementation Yes AC08 - Has a secure electronic system for two-way communication to provide timely clinical advice Elective Documented process AND Yes Report Yes AC09 - Uses information about the population served by the practice to assess equity of access Elective Evidence of implementation No AC10 - Helps patients/caregivers select or change a personal clinician Core Documented process Yes AC11 - Sets goals and monitors the percentage of patient visits with the selected clinician or team Core Report No AC12 - Provides continuity of medical record information for care and advice when the office is closed Elective Documented process Yes AC13 - Reviews and actively manages panel size Elective Documented process AND Yes Report No AC14 - Reviews and reconciles panels based on health plan or other outside patient assignments Elective Documented process AND Yes Evidence of implementation No Criterion for Care Management (CM) Core vs. Elective Evidence Type Eligible CM01 - Considers 3 out of 5 NCQA measures when identifying patients who may benefit from care management Core Protocol for identifying patients for care management OR Yes CM03 Yes CM02 - Monitors the percentage of the total patient population identified through its process and criteria Core Report No CM03 - Applies a comprehensive process for patient Elective Report Yes CM04 - Establishes a care plan for patients identified for care management Core Report OR No [Record Review Workbook and No Patient examples] No CM05 - Provides a written care plan to the patient/family/caregiver for patients identified for care management Core Report OR No [Record Review Workbook and No Patient examples] No CM06 - Documents patient preference and functional/lifestyle goals in individual care plans Elective Report OR No [Record Review Workbook and No Patient examples] No CM07 – Identify and discuss potential barriers to meeting goals in individual care plans Elective Report OR No [Record Review Workbook and No Patient examples] No
2017%20PCMH%20SBHC%20Criterion%20List%20(1).docx