leveraging the medical neighborhood manual the medical neighborhood manual...prisma health-midlands,...
TRANSCRIPT
Leveraging the Medical Neighborhood
Wednesday, March 20, 2019Webinar 2:00 p.m. – 3:30 p.m. ET
Information presented in this NCQA Education program is verified for accuracy before its presentation. In the event of any real or perceived conflict with an NCQA publication, the publication and/or any in-force published correction, clarification or policy change, including a Frequently Asked Question (FAQ) or Policy Update document posted on the NCQA Website, takes precedence.
© (2019) by the National Committee for Quality Assurance 1100 13th Street, NW, Third Floor, Washington, DC 20005 202/955-3500 202/955-3599 (fax) www.ncqa.org All rights reserved. Printed in the USA.
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Table of Contents
Section 1 Webinar Information Section 2 Slide Presentation Section 3 Resources
Webinar Information
Leveraging the Medical Neighborhood
This webinar will examine the opportunities and benefits practices can experience when they take the initiative to collaborate with their neighborhood counterparts (other clinics and practices, PCMH, PCSP, Oncology Medical Home and Patient-Centered Connected Care practices/clinics). Understand how to connect and encourage a symbiotic relationship to optimize criteria selection and improve patient care. Learn the similarities amongst recognition standards’ sets and identify opportunities for improving coordination and efficiency across the medical neighborhood. Faculty will share successful examples of transformation and collaboration across a variety of practice settings within both independent practices and integrated delivery systems.
Agenda Welcome Tammy Donnelly, NCQA
Presenters Nicole Mason, MA, PCMH CCE, NCQA Leigh Reddick, BS, PCMH CCE, Prisma Health
Open Discussion/Question and Answer Session
Closing Remarks Tammy Donnelly, NCQA
Objectives At the end of the program, participants will be able to:
• Describe how the fundamentals of the patient-centered approach to care align across providers within the medical neighborhood.
• Identify similarities across NCQA Recognition programs to support optimization of criteria selection associated with coordination of care.
• Pinpoint strategies for coaching, engaging and leading teams across organizations and departments to gain buy-in and adopt clinical guidelines, standing orders and protocols.
• Develop and implement a blueprint for how providers can work together to share policies and procedures for care coordination that enables all participating organizations to overcome barriers and improve care.
Continuing Education This live webinar grants 2.0 required Continuing Education Unit (CEU) points for PCMH Certified Content Experts. This is a non-AMA PRA Category 1 Credit™, AAPA Prescribed Credit, ANA CNE, APA, ACPE and ASWB ACE activity.
Disclosure of Relevant Financial Relationships
Leveraging the Medical Neighborhood March 20, 2019
The National Committee for Quality Assurance (NCQA) endorses the Standards of the Accreditation Council for Continuing Medical Education which specify that sponsors of continuing medical education activities and presenters at and planners for these activities disclose any relevant financial relationships either party might have with commercial companies whose products or services are discussed in educational presentations. For sponsors, relevant financial relationships include large research grants, institutional agreements for joint initiatives, substantial gifts, or other relationships that benefit the institution. For presenters or planning committee members, relevant financial relationships include the receipt of research grants from a commercial company, consultancies, honoraria, travel, or other benefits, or having a self-managed equity interest in a company; or having an immediate family member or partner with such a relationship. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. Relevant financial relationships exist with the following companies/organizations:
Faculty:
Nicole Mason: None Leigh Reddick: None Additional Planning Committee: Tammy Donnelly: None
This program was developed in part by NCQA staff. This program received no commercial support.
Faculty
Nicole, Mason, MA, PCMH CCE Assistant Director, Product Development NCQA
Leigh Reddick, BS, PCMH CCE Director of Community Quality Programs, Population Health Management Prisma Health-Midlands
Faculty Biographies
Nicole Mason, MA, PCMH CCE
Nicole Mason is an Assistant Director in NCQA’s Product Development Department. In this role, she oversees new Recognition Program product development and program maintenance, leveraging her prior experience as a Policy Manager in the Recognition Programs Policy and Resources Department. On this team, she supported multiple aspects of the programs, including development, implementation and maintenance, through creation and update of resources, management of product updates and facilitation of training for both internal staff and external customers. In early 2017, she also led the product development and launch of NCQA’s first specialty-specific recognition program, the Oncology Medical Home, and she has played a key role in the implementation and support of the redesign of NCQA’s Recognition Programs.
She started at NCQA in the Performance Measurement Department where she supported government contracts to develop of electronic clinical quality measures, a PCORI-funded patient-centered oncology research project, and the maintenance and analysis of the HEDIS respiratory measure suite.
Before joining NCQA, she worked as a post-baccalaureate fellow at the National Heart, Lung, and Blood Institute where she supported research projects to investigate aplastic anemia. She holds a BA in Biochemistry and Molecular Biology, BA in Psychology, and MA in Biotechnology from Boston University in Boston, MA.
Leigh Reddick, BS, PCMH CCE
Leigh Reddick is the Director of Community Quality Programs, Population Health Management at Prisma Health-Midlands, the largest and most comprehensive integrated health care system in the South Carolina Midland region.
Leigh has a BS in Human Services for the University of South Carolina and earned PCMH Content Expert Certification in 2013. In her 5 years as Director of Community Quality Programs at Prisma Health-Midlands, the system has embraced the PCMH experience. The Prisma Health Midlands Network practice includes primary care offices, specialty offices and a connected care office.
Palmetto Heart was the first specialty practice in the state of South Carolina to be recognized as a Patient-Centered Specialty Practice (2015). The Palmetto Health Infusion Center was honored as the first infusion center in the United States to earn Patient-Centered Connected Care Recognition (2016). Leigh continues to provide guidance and support as offices are transformed and “live” the patient-centered process. Leigh is a 2018-2019 PCMH CCE Quality Award winner.
Slide Presentation
Leveraging the Medical Neighborhood
March 20, 2019
1
All materials © 2018, National Committee for Quality Assurance
Agenda
1. Describe how the fundamentals of the
patient-centered approach to care align
across providers within the medical
neighborhood.
2. Identify similarities across NCQA
Recognition programs to support
optimization of criteria selection associated
with coordination of care.
3. Pinpoint strategies for coaching, engaging
and leading teams across organizations and
departments to gain buy-in and adopt
clinical guidelines, standing orders and
protocols.
4. Develop and implement a blueprint for how
providers can work together to share
policies and procedures for care
coordination that enables all participating
organizations to overcome barriers and
improve care.
Program
Objectives
Program Faculty
Nicole Mason, MA, PCMH CCE
Assistant Director, Product Development
NCQA
Leigh Reddick, BS, PCMH CCE
Director of Community Quality Programs
Population Health Management
Prisma Health- Midlands
3
↑Access ↑Quality ↓Cost Desired Future
4
Fragmentation Continues2015 Malpractices Risks in Communication Failures Report1
51Malpractice Risks in Communication Failures. 2015 CRICO Strategies National CBS Report. https://www.rmf.harvard.edu/Malpractice-
Data/Annual-Benchmark-Reports/Risks-in-Communication-Failures
57% of the cases
reflected miscommunication
between two or more
healthcare providers
48% of
miscommunication
happened in ambulatory
settings$1.7 Billion
2,000 Lives
Costs:
NCQA’s Recognition Programs
6
PCMH Concepts
7
Team-Based Care and
Practice Organization
(TC)
Knowing and
Managing Your
Patients (KM)
Patient-Centered
Access and Continuity
(AC)
Care Management and
Support (CM)
Care Coordination
and Care Transitions
(CC)
Performance
Measurement &
Quality Improvement
(QI)
PCSP & Oncology Medical Home Concepts
Team-Based Care
and Practice
Organization (TC)
Knowing and
Managing Your
Patients (KM)
Patient-Centered
Access and
Continuity (AC)
Plan and Manage
Care (PM)
Care Coordination
and Care
Transitions (CC)
Performance
Measurement &
Quality Improvement
(QI)
Initial Referral
Management
(RM)
8
Patient-Centered Connected Care Standards
Standard 1:
Connecting With
Primary Care
Standard 2:
Identifying Patient
Needs
Standard 3:
Patient Care and
Support
Standard 4:
System
Capabilities
Standard 5:
Measure & Improve
Performance9
Cross-Program
Shared Credit
Option
10
Cross-Program Credit is AvailableFor Organizations Pursuing Multiple Recognitions
Example:
An organization with PCMH & PCSP
could share the following in TC & KM:
✓ Certified EHR Technology
✓ Comprehensive Health
Assessment (where aligned)
✓ Behavioral Health Screenings
(where aligned)
✓ Controlled Substance Database
Review
✓ Prescription Claims Database
11
12
A Blueprint for Quality Care
✓ Transformation
✓ Internal care team
communication
✓ External care team
communication
13
Polling Question
Have you supported organizations to implement patient-centered care delivery across the medical neighborhood (i.e., PCMH, PCSP, Connected Care)?
A.Yes, I’ve supported practices across programs.
B.Yes, I’ve supported PCMH and PCSP practices.
C.No, I mainly support PCMH practices.
Title and content
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14Floating footnote placeholder box – copy & paste as needed
Subtitle
PCMH
SBMH
PCSPPCSP
Connected Care
Connected Care
Connected Care
Connected Care
Oncology Medical
Home
Medical Neighborhood AlignmentComplementary Recognition Program Concepts
15
PCMH (2017) PCSP (2019) &
Oncology Medical
Home (2019)
Connected Care 2015
TC TC Standard 2: Identifying Patient Needs
RM Standard 1: Connecting with Primary
Care
KM KM Standard 3: Patient Care and Support
Standard 4: System Capabilities
AC AC
CM PM Standard 3: Patient Care and Support
CC CC Standard 2: Identifying Patient Needs
Standard 3: Patient Care and Support
QI QI Standard 5: Measure & Improve
Performance
Title and content
If body subhead is needed on this line,
override and make text bold and red.
Default text style. Use Tab to add bullet.
Keep words to a minimum with these suggested limits:
• 5 words per line.
• 10 words per text block.
• 50 words per slide. • Sub-bullet style
16Floating footnote placeholder box – copy & paste as needed
Subtitle
17
18
The Medical Neighborhood & The Triple Aim
Aligning Care Delivery to
Improve Quality
LEIGH REDDICK, BS, PCMH CCE
Prisma Health
Medical NeighborhoodPCMH, PCSP and Patient Centered Connected Care
20
For Patients Healthcare Can Feel Like a Maze
21
Polling Question
A. Primary Care Practice
B. Specialty Care Practice
C. Oncology Practice
D. Patient-Centered Connected Care (urgent care centers, retail clinics,
worksite health clinics and others)
E. School Based Medical Center
What type of organization do you primarily represent?
22
Polling Question
A. Independently Owned Medical Practice or Clinic
B. Integrated / Larger Health System
What type of system do you represent?
23
Alignment at Prisma Health
The Start of Our PCMH Transformation Journey
Began with Improving Quality for Geriatric Patients
25
What is PCMH? PCSP? Connected Care?
Prisma Health Level Sets with Shared Definitions
PCMH
A model for Primary Care provided
by physician practices that seeks
to strengthen the physician‐patient
relationship by replacing episodic
care based on illnesses and
patient complaints with
coordinated care and a long‐term
healing relationship.
PCSP
A model for Specialty Care provided
by physician specialty practices that
seeks to strengthen the
physician‐patient care coordination
relationships.
Patient‐Centered
Connected Care
A model for Ancillary Medical
Care provided by outpatient
providers that seeks to
strengthen the
physician‐patient relationship
by enhancing patient care by
filling and/or providing
specific needs of the patient.
The office focus is on the patient
and their needs, their families and
caregivers. Being pro-active
instead of reactive with patient
care, giving quality care and
improving patient experience.
The office focus is on the patient
and their needs, their families and
caregivers. Being able to give quick
referral appointments. Timely
sharing and communication of
patient- specialty care information to
the patient/family/caregiver and also
back to the patient’s Primary Care
Provider.
The office focus is on the
patient and their needs, their
families and caregivers with
attention to areas of specific
needs/concerns. (i.e. Urgent
Care, Infusion Center)
26
Each Member of the Team Has Responsibilities
Defining Success for Physicians and Providers
PCMH PCSP Patient Centered Connected
Care
PHYSICIANS/PROVIDERS:
Address patient concerns with
goals, behavioral health, lifestyle,
and barriers. Address
medications, labs, referrals,
screenings and behavioral health.
Encourage patient education and
self management.
PHYSICIANS/PROVIDERS:
Address referral
concerns/diagnosis and work
together with primary care
providers to address patient
concerns with goals, behavioral
health, lifestyle, medications, and
barriers in regards to the referral
focus. Ensures a Referral Report is
completed and sent back to the
patient’s Primary Care Provider in
a timely manner.
PHYSICIANS/PROVIDERS:
Address the specific need and/or
concern for the patient. Ensures a
report is completed and sent back
to the patient’s Primary Care
Provider in a timely manner.
27
Each Member of the Team Has Responsibilities
Defining Success for Clinical Staff
PCMH PCSP Patient Centered Connected
Care
CLINIC STAFF:
Ensures Comprehensive Intake
during a patient visit including
but not limited to vitals, height,
weight, medication review, etc.
Also ensures patients labs,
tests, referrals were done,
provider aware of results, and
patient notified of results.
Assist Providers, as able, with
their responsibilities.
CLINIC STAFF:
Ensures Comprehensive Intake
during a patient visit including
but not limited to vitals, height,
weight, medication review, etc.
Also ensures patients labs,
tests, referrals were done,
provider aware of results, and
patient notified of results.
Assist Providers, as able, with
their responsibilities.
CLINIC STAFF:
Ensures a completed intake
during a patient visit related to
specific areas. Also ensures
patients labs, tests, referrals
were done, provider aware of
results, and patient notified of
results. Assist Providers, as
able, with their responsibilities.
28
Each Member of the Team Has Responsibilities
Defining Success for Front Office Staff
PCMH PCSP Patient Centered Connected
Care
FRONT OFFICE STAFF:
Collects and documents patient
data like DOB, sex, race,
insurance, telephone and address.
Medical Records
FRONT OFFICE STAFF:
Collects and documents patient
data like DOB, sex, race,
insurance, telephone and address.
Confirms patient’s Primary Care
Provider is noted in patient record.
If the patient does not have a
Primary Care Provider, they assist
the patient to obtain one within the
Palmetto Health system.
FRONT OFFICE STAFF:
Collects and documents patient
data like DOB, sex, race,
insurance, telephone and address.
Confirms patient’s Primary Care
Provider is noted in patient record.
If the patient does not have a
Primary Care Provider, they assist
the patient to obtain one within the
Palmetto Health system.
29
• Standardization of Policies, procedures and processes
• Improved access for patients
• Standardized Comprehensive Intake
• Daily Huddle for patient care
• Standardized education of onboarding and ongoing staff training
• Accountability and coaching easier for managers
• Improvement in “closing the loop” for laboratory/Imaging tests
• Improved patient satisfaction scores
• Better health care quality
• Improved involvement of patients in their own care
• Reduction of avoidable cost over time
PCMH Benefits Recognized Across Prisma Health
30
• Scheduling staff continued to have difficulty at times setting up
referral appointments.
• Referrals were being followed, but clinic staff reported slow turn
around time in obtaining Referral/Consult Report.
• Referrals were not always comprehensive, sometimes vague
in their report
• There was an opportunity to open dialog with the specialty practices.
• Staff Turn over
Opportunities Discovered During the Process
31
The Start of our PCSP Journey
32
Pursuing Patient Centered Connected Care
33
Shared Goals and Common Ground
Examples
Access for Patients Visits – Same Day Visit (SDV)
Providers (Primary and Specialty) have SDV slots –
Monitored by Third Next Process
Patient Centered Access
35
Patient Experience Survey (CG-CAHPS)
Patient Centered Access continued
36
Telephone Calls for Clinical Advice During and After
Hours
Patient Centered Access Continued
37
Electronic Communication with Patients - Portal
Patient Centered Access Continued
38
Standardization of Policies and Procedures for
Primary and Specialty Offices across Prisma Midland’s Network
Team Based Care
39
Organizational Development
Team Based Care Continued
40
Meetings for Office and Patient Information
Team Based Care Continued
41
Demographic Assessment
Race, Language, Ethnicity, Insurance, DOB, etc. to
Determine Patient Needs
Population Health: Knowing and Managing Patients
42
Comprehensive Assessment
Vitals, Medications, Allergies, Social and Family
Histories, etc.
Population Health ContinuedKnowing and Managing your Patients
43
Screening and Prevention Updates and Reminders
Tobacco Use, Fall Risk, Depression, Breast Cancer,
Colorectal Cancer etc.
Population Health ContinuedKnowing and Managing Patients
44
Patient Support with Care Planning, Goals, Self-
Management, Addressing Barriers
Care Management
45
Patient Support with Care Planning, Goals, Self-
Management, Addressing Barriers
Care Management Continued
46
Laboratory, Radiology and Referral Tracking
Care Coordination
47
Laboratory, Radiology and Referral Tracking
Care Coordination Continued
48
Review Quality Results with Offices and Providers
Performance Measurement & Quality Improvement
49
Office Start Results – BLUE BAR
Following Year with PCMH Results – RED BAR
Performance Measurement & Quality ImprovementActual Results of a Prisma Physician Office
50
New Name: Prisma Health Midlands Network
51
Benefits of the Patient Centered & ACO Collaboration
Providers meet together, they are more engaged and willing to
participate in quality improvements to improve patient care
Ongoing improvement in scores and quality in other programs –
i.e. MSSP, MACRA, GPRO, Gaps in Care, and HEDIS
Aligning PCMH/PCSP standards with the quality programs, offices
now have a unified focus and are not as overwhelmed with differing
goals
52
Benefits Continued
Most importantly the Patient-Centered philosophy has helped
providers, clinical staff and ancillary staff to work together to
advance quality of care for patients/families/caregivers
Financial Incentives were realized - Previous Payer Source Example:
53
Recognition Accomplishments
54
Questions
55
After the Webinar
Continue the conversation with faculty and other CCEs
in the PCMH CCE Digital Community.
Share your experiences,
ask questions and learn
about how others are
coordinating across the
medical neighborhood.
Access the PCMH CCE Digital Community through “My
Apps” at http://My.NCQA.org
56
Thank you
PCMH CCE Resources
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Page 1 of 2
Palmetto Health Physician Practice Network Patient Telephone Calls for Advice
Effective: Not Yet Approved Reviewed: Revised: Name of Associated Policy: Palmetto Health Physician Practice Network Patient Centered Medical Home Policy RESPONSIBLE PERSONS:
- Provider and non-provider staff PROCEDURE STEPS, GUIDELINES, RULES, OR REFERENCE 1. Guideline
1.1. Palmetto Health Physician Practice staff will assist callers in the evaluation of health
care needs and in selection of service options.
2. Rules
2.1. Provider and non-provider staff is available to assist callers during office hours. 2.2. The staff will identify the patient’s issue or concerns and assist the patient with
selecting appropriate service options based on triage assessment. 2.3. After business hours, a provider will be on-call for urgent issues.
2.3.1. The on-call provider may be reached by dialing the office number. 2.3.2. Phones will be forwarded to the answering service after hours.
2.3.2.1. The answering service will be responsible for contacting the on-call provider or directing patients to web-based services.
2.3.3. The on-call provider will respond to urgent requests within one (1) hour. 2.3.4. If the on-call provider receives a patient call warranting care when the office is
closed, the patient will be directed to a Palmetto Health Urgent Care location or a Palmetto Health Emergency Department.
2.3.4.1. Providers at both types of facilities will have access to the patient’s electronic chart when the office is closed.
3. Front Office Procedure
3.1. During business hours, if a patient call is received by the front office staff and the caller
identifies a clinical inquiry including a new symptom, illness or concern, the phone call will be directed to a clinical staff member for triage.
Palmetto Health Physician Practice Network Patient Telephone Calls for Advice
Page 2of 2
3.1.1. If a clinical staff member is unavailable, a message will be taken or the call may be routed to voicemail which will be reviewed by a clinical staff member.
3.1.1.1. A return phone call to the patient will be returned in a timely manner. 3.1.1.2. All patient messages regarding medical care will be addressed within 24
hours of the patient’s call. 3.1.1.2.1. The practice response time standard is that 100% of calls will be
returned within 24 hours.
4. Clinical Staff Procedure 4.1. Answer the telephone professionally using Palmetto Health standard phone greeting. 4.2. Obtain and document information regarding current signs and symptoms. In addition,
obtain pertinent medical history if applicable. 4.3. Determine the urgency of call based upon identification of patient needs.
4.3.1. If warranted or requested, schedule an appointment for the patient with the primary provider for orders or questions, inform the patient (or person calling on behalf of the patient) that information will be forwarded to the physician and a return call will be made as soon as possible.
4.3.2. The staff will ensure the return call is made in a timely manner 4.3.2.1. All calls are expected to be returned and documented in the medical record
within 24 business hours. 4.3.2.2. Clinical advice will be documented in the patient’s electronic health record.
4.3.3. All emergency calls will be taken immediately or directed to seek emergency care at the nearest emergency department or Urgent Care location.
Page 1 of 1
Palmetto Health Physician Practice Network Patient Telephone Language Line Services
Effective: Not Yet Approved Reviewed: Revised: Name of Associated Policy: Palmetto Health Physician Practice Network Patient Centered Medical Home Policy RESPONSIBLE PERSONS:
- Provider and non-provider staff PROCEDURE STEPS, GUIDELINES, RULES, OR REFERENCE 1. Guideline
1.1. The Palmetto Health Physician Practice Network will provide language line services for
translation purposes when a patient does not speak English as their primary language. When a patient is unable to communicate in English, clinical staff will obtain an appropriate Interpreter by using the Language Line provided in the office.
2. Procedure
2.1. For patients who speak Spanish, call 434-8500 for translation services. 2.2. For all other languages, call 1-877-746-4674
2.2.1. The Operator will introduce him or herself and then ask you, “What language do you need?”
2.2.2. Then the Operator will ask, “Where are you calling from.” (Palmetto Health needs to be identified before your hospital)
2.2.3. You will be asked for the following information: ▪ Location ▪ First and Last Name ▪ Department
2.2.4. Next the Operator will place you on “hold” while they get an interpreter. 2.2.5. Then the Operator will come back on the line with the interpreter also on the line.
Finally, the Operator will confirm that all parties are present, and then exit the conference call leaving you connected with the Interpreter to service your needs.
Page 1 of 1
Palmetto Health Physician Practice Network Open Access Scheduling for Patient Centered Medical Home Offices
Effective: Not Yet Approved Reviewed: Revised: Name of Associated Policy: Palmetto Health Physician Practice Network Patient Centered Medical Home Policy RESPONSIBLE PERSONS:
- Provider and non-provider staff PROCEDURE STEPS, GUIDELINES, RULES, OR REFERENCE 1. Guidelines for Open Access Scheduling
1.1. Each business day, provider schedules will have slots reserved to allow time for patients needing or requesting a same-day appointment to be seen. If a patient calls and requests an appointment, they will be scheduled on that date with their routine provider into a reserved same day visit slot.
1.2. If the primary provider’s reserved slots on that day have already been filled, the staff will consult with the primary provider regarding appropriate care for the patient.
1.2.1. If no slots are available, the clinical staff will communicate with the primary provider to see if the visit can wait for the next day or next-available opening.
1.2.2. If the determination is that the visit cannot wait, the patient can be: ▪ Added to the provider’s full appointment schedule (at the provider’s
discretion) ▪ See any available provider at the office or the patient can be referred to a
Palmetto Health Urgent Care location. o Physician staff at each urgent care location will have access to the
patient’s electronic chart information. In the event a patient is sent to one of these locations, the primary provider or provider’s delegate will notify the convenience care office staff of the patient’s need for medical attention along with pertinent medical information.
1.3. If the primary provider feels that emergent care is warranted, the patient will be referred to an emergency department
1
Making the Business Case for Patient Engagement
After the webinar, continue the conversation with Leigh Reddick, BS, PCMH CCE and Nicole Mason, MA, PCMH CCE in the PCMH CCE Digital Community.
Share your experiences, ask questions and learn about how others are leveraging the medical neighborhood.
Access the PCMH CCE Digital Community through “My Apps” at My.NCQA.org
2
Instructions to Access the PCMH CCE Digital Community The community is a place where you and your CCE colleagues can discuss various subjects regarding the medical home, practice transformation and quality improvement.
Registration is simple!
Step 1. Log into your https://my.ncqa.org/ account.
Step 2. Click My Apps.
Step 3. Click PCMH CCE Digital Community. You will automatically be signed on through your my.NCQA credentials.
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Patient-
Cente
red
Spe
cia
lty P
ractice (
PC
SP
)
NC
QA
PC
SP
to
PC
MH
Cro
ssw
alk
January
29,
20
19
pa
ge 1
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Evid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
.
Th
e t
ab
le b
elo
w c
om
pa
res N
CQ
A’s
Patie
nt-
Ce
nte
red
Sp
ecia
lty P
ractice (
PC
SP
) sta
nd
ard
s (
20
19
ed
itio
n)
with
the
P
CM
H (
20
17
editio
n)
pro
gra
m r
eq
uirem
en
ts.
Re
ad
ing
th
e C
olu
mn
s:
•
Ali
gn
me
nt
No
tes
: C
om
pa
res s
pecific
PC
SP
crite
ria
to P
CM
H c
rite
ria
an
d ide
ntifie
s ite
ms t
ha
t are
th
e s
am
e o
r sim
ilar
an
d n
ote
s d
iffe
ren
ces.
Th
e k
ey b
elo
w e
xp
lain
s t
he s
ym
bo
ls.
•
Sh
are
d C
red
it O
pti
on
Wit
h P
CM
H:
Mu
lti-site o
rgan
ization
s s
eekin
g P
CS
P w
ith
exis
tin
g o
r co
ncu
rre
nt P
CM
H
reco
gn
itio
n m
ay s
tre
am
line
th
eir r
eco
gn
itio
n b
y s
ha
rin
g c
rite
ria b
etw
ee
n th
e p
rog
ram
s.
Th
is c
olu
mn
de
note
s th
e
sp
ecific
sh
are
d c
red
it a
lign
me
nt.
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
Te
am
-Bas
ed
Ca
re a
nd
Pra
cti
ce
Org
an
iza
tio
n (
TC
)
TC
01 (
Co
re)
T
ran
sfo
rmati
on
Lead
s
TC
01 (
Co
re)
PC
MH
Tra
nsfo
rmati
on
Le
ad
s
✔
No
TC
02 (
Co
re)
S
tru
ctu
re a
nd
Sta
ff R
esp
on
sib
ilit
ies
T
C 0
2 (
Co
re)
S
tru
ctu
re a
nd
Sta
ff R
esp
on
sib
ilit
ies
✔
N
o
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 2
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
TC
03 (
1 C
red
it)
C
ollab
ora
tio
n w
ith
th
e M
ed
ical
Neig
hb
orh
oo
d
TC
03 (
1 C
red
it)
Exte
rnal
PC
MH
Co
llab
ora
tio
ns
✔
N
o
TC
04 (
2 C
red
its)
Pati
en
ts/F
am
ilie
s/C
are
giv
ers
In
vo
lvem
en
t in
Go
vern
an
ce
TC
04 (
2 C
red
its)
Pati
en
ts/F
am
ilie
s/C
are
giv
ers
In
vo
lvem
en
t in
Go
vern
an
ce
✔
N
o
TC
05 (
2 C
red
its)
C
ert
ifie
d E
HR
Syste
m
TC
05 (
2 C
red
its)
Cert
ifie
d E
HR
Syste
m
✔
Yes
TC
06 (
Co
re)
In
div
idu
al P
ati
en
t C
are
M
eeti
ng
s/C
om
mu
nic
ati
on
TC
06 (
Co
re)
Ind
ivid
ual P
ati
en
t C
are
M
eeti
ng
s/C
om
mu
nic
ati
on
✔
N
o
TC
07 (
Co
re)
S
taff
In
vo
lvem
en
t in
Qu
ality
Im
pro
vem
en
t
TC
07 (
Co
re)
Sta
ff In
vo
lvem
en
t in
Qu
ality
Im
pro
vem
en
t ✔
N
o
TC
08 (
Co
re)
S
pecia
lty P
racti
ce
In
form
ati
on
T
C 0
9 (
Co
re)
Med
ical H
om
e In
form
ati
on
✔
N
o
Init
ial
Refe
rra
l M
an
ag
em
en
t (R
M)
RM
01 (
Co
re)
S
ett
ing
Exp
ecta
tio
ns W
ith
Refe
rrin
g
Clin
icia
ns
CC
08 (
1 C
red
it)
Sp
ecia
list
Refe
rral
Exp
ec
tati
on
s
✔
No
RM
02 (
1 C
red
it)
A
gre
em
en
ts W
ith
Refe
rrin
g
Clin
icia
ns
CC
08 (
1 C
red
it)
Sp
ecia
list
Refe
rral
Exp
ec
tati
on
s
Co
mp
lem
en
tary
alig
nm
en
t. A
n
agre
em
ent fo
rmed b
etw
een
a
refe
rrin
g P
CM
H o
r a r
efe
rrin
g
specia
list cou
ld b
e u
sed t
o m
eet
PC
MH
CC
08 a
nd P
CS
P R
M 0
2
No
RM
03 (
Co
re)
Co
mm
un
icati
ng
Refe
rral
Req
uests
N
o e
qu
ivale
nt
X
No
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 3
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
RM
04 (
Co
re)
Veri
fies R
ec
eip
t o
f In
form
ati
on
C
C 0
4 (
Co
re)
A a
nd
C
Refe
rral M
an
ag
em
en
t
Co
mp
lem
en
tary
Alig
nm
en
t:
Receiv
ing c
om
ple
te info
rmatio
n
from
the P
CM
H s
upport
s t
he
refe
rral m
anagem
ent pro
cess in
PC
SP
.
No
RM
05 (
Co
re)
G
ath
eri
ng
In
form
ati
on
No
t In
itia
lly
Receiv
ed
N
o e
qu
ivale
nt
X
No
RM
06 (
Co
re)
Fo
llo
w-U
p A
fter
Mis
sed
Ap
po
intm
en
ts a
nd
C
an
cell
ati
on
s
No
eq
uiv
ale
nt
X
No
RM
07 (
Co
re)
Resp
on
se t
o P
rim
ary
Ca
re a
nd
R
efe
rrin
g C
lin
icia
ns
C
C 1
1 (
1 C
red
it)
Refe
rral
Mo
nit
ori
ng
Co
mp
lem
en
tary
Alig
nm
en
t:
Pro
vid
ing
com
ple
te info
rmation
support
s th
e r
efe
rral m
onito
ring
pro
cess in P
CM
H.
No
RM
08 (
Co
re)
Do
cu
men
tin
g P
rim
ary
Ca
re C
lin
icia
n
No
eq
uiv
ale
nt
X
No
RM
09 (
1 C
red
it)
Co
mm
un
icate
s t
he
Im
po
rtan
ce o
f F
ollo
w-U
p W
ith
P
rim
ary
Ca
re
No
eq
uiv
ale
nt
X
No
RM
10 (
1 C
red
it)
C
on
necti
ng
Pati
en
ts W
ith
Pri
mary
C
are
N
o e
qu
ivale
nt
X
No
RM
11 (
Co
re)
Co
nta
cti
ng
th
e P
rim
ary
C
are
Clin
icia
n P
rio
r to
Tre
atm
en
t N
o e
qu
ivale
nt
X
No
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 4
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
Kn
ow
ing
an
d M
an
ag
ing
Yo
ur
Pa
tie
nts
(K
M)
KM
01 (
Co
re)
P
ati
en
t-S
pe
cia
list
Re
lati
on
sh
ip
CC
12 (
1 C
red
it)
Co
-Man
ag
em
en
t A
rran
gem
en
ts
Part
ial
Alig
nm
en
t.
No
KM
02 (
Co
re)
M
ed
ical H
isto
ry a
nd
Pro
ble
m L
ist
Do
cu
men
tati
on
KM
01 (
Co
re)
P
rob
lem
Lis
ts a
nd
KM
02 (
Co
re)
A
Med
ical h
isto
ry o
f p
ati
en
t an
d f
am
ily
✔
N
o
KM
03 (
1 C
red
it)
P
red
om
inan
t C
on
dit
ion
s a
nd
C
on
cern
s
KM
06 (
1 C
red
it)
Pre
do
min
an
t C
on
dit
ion
s a
nd
Co
ncern
s
✔
No
KM
04 (1
Cre
dit
)
Sp
ecia
list
Co
mp
reh
en
siv
e H
ea
lth
A
sse
ssm
en
t
KM
02 (
Co
re)
B, C
, D
, E
, I
Co
mp
reh
en
siv
e H
ealt
h A
sses
sm
en
t
Part
ial ali
gn
men
t. P
CS
P a
lso
assesses p
ain
assessm
ent/fu
nctiona
l assessm
ent
(PC
SP
KM
04 E
) and
patie
nt
pre
fere
nces a
nd p
ers
on
al h
ealth
goa
ls (
KM
04 F
)
Part
iall
y S
ha
red
**
KM
05 (
1 C
red
it)
Beh
av
iora
l H
ealt
h S
cre
en
ing
s
KM
03 (
Co
re),
KM
04 (
1 C
red
it)
A-G
P
art
ial a
lig
nm
en
t. P
CS
P inclu
de
s
cognitiv
e im
pairm
ent (K
M 0
5 I)
an
d
dis
tress (
KM
05 J
).
Part
iall
y S
ha
red
**
KM
06 (
Co
re)
Div
ers
ity
KM
09 (
Co
re)
Div
ers
ity
✔
No
KM
07 (
Co
re)
Lan
gu
ag
e
KM
10 (
Co
re)
Lan
gu
ag
e
✔
No
KM
08 (
2 C
red
its)
Sta
ff C
ult
ura
l C
om
pete
nce a
nd
He
alt
h L
itera
cy
Skills
K
M 1
1 P
op
ula
tio
n N
eed
s
✔
No
KM
09 (
Co
re)
D
ocu
men
t an
d R
eco
ncil
e
Med
icati
on
s
KM
14 (
Co
re)
Med
icati
on
Reco
ncil
iati
on
an
d K
M 1
5 (
Co
re)
Med
icati
on
Lis
ts
✔
No
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 5
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
KM
10 (
1 C
red
it)
N
ew
Pre
scri
pti
on
Ed
ucati
on
K
M 1
6 (
1 C
red
it)
New
Pre
scri
pti
on
E
du
cati
on
✔
N
o
KM
11 (
Co
re)
M
an
ag
ing
Med
icati
on
Wit
h t
he C
are
T
eam
N
o e
qu
ivale
nt
X
No
KM
12 (
1 C
red
it)
M
ed
icati
on
Resp
on
ses a
nd
Barr
iers
K
M 1
7 (
1 C
red
it)
Med
icati
on
Resp
on
se
s
an
d B
arr
iers
✔
N
o
KM
13 (
1 C
red
it)
C
on
tro
lled
Su
bsta
nce D
ata
base
Rev
iew
KM
18 (
1 C
red
it)
Co
ntr
olle
d S
ub
sta
nc
e
Data
bas
e R
ev
iew
✔
Y
es
KM
14 (
2 C
red
its)
P
resc
rip
tio
n C
laim
s D
ata
K
M 1
9 (
2 C
red
its)
Pre
scri
pti
on
Cla
ims D
ata
✔
Y
es
KM
15 (
Co
re)
Pro
acti
ve R
em
ind
er
KM
12 (
Co
re)
Pro
acti
ve O
utr
each
Part
ial a
lig
nm
en
t. P
CM
H s
pecifie
s
that re
min
ders
must be a
cro
ss
specific
cate
gori
es a
nd r
eq
uires a
t le
ast
3 p
roactive r
em
inders
.
No
KM
16 (
1 C
red
it)
A
dd
itio
nal
Pro
acti
ve R
em
ind
ers
N
o
KM
17 (
Co
re)
C
lin
ical
Dec
isio
n S
up
po
rt
KM
20 (
Co
re)
Clin
ica
l D
ec
isio
n S
up
po
rt
Part
ial a
lig
nm
en
t. P
CM
H s
pecifie
s
that clin
ical decis
ion s
upport
must
dem
onstr
ate
at
least
4 d
iffe
rent
conditio
ns/issues.
No
KM
18 (
1 C
red
it)
A
dd
itio
nal
Clin
ical D
ecis
ion
S
up
po
rts
N
o
KM
19 (
1 C
red
it)
P
ath
ways
fo
r S
ym
pto
m M
an
ag
em
en
t N
o e
qu
ivale
nt
X
No
KM
20 (
2 C
red
its)
E
xc
ellen
ce in
Pe
rfo
rman
ce
K
M 1
3 (
2 C
red
its)
E
xc
ellen
ce in
Pe
rfo
rman
ce
✔
N
o
KM
21 (
1 C
red
it)
S
hare
d D
ecis
ion
-Makin
g A
ids
K
M 2
4 (
1 C
red
it)
Sh
are
d D
ecis
ion
-Makin
g A
ids
✔
N
o
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 6
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
Pa
tie
nt-
Cen
tere
d A
cc
es
s a
nd
Co
nti
nu
ity (
AC
)
AC
01 (
Co
re)
A
cce
ss f
or
Urg
en
t N
eed
s
AC
01 (
Co
re)
Ac
ces
s N
ee
ds a
nd
P
refe
ren
ces
Par
tial
alig
nm
en
t. P
CSP
is s
pec
ific
to
urg
ent
nee
ds
wh
ile P
CM
H r
efe
rs
to b
oth
ro
uti
ne
and
urg
ent
app
oin
tmen
t ac
cess
.
No
AC
02 (
Co
re)
T
imely
Clin
ica
l A
dv
ice b
y T
ele
ph
on
e
AC
04
(C
ore
) T
imely
Cli
nic
al
Ad
vic
e b
y
Tele
ph
on
e
✔
Part
iall
y S
ha
red
**
AC
03 (
1 C
red
it)
P
ati
en
t P
ort
al
AC
07 (
1 C
red
it)
Ele
ctr
on
ic P
ati
en
t R
eq
uests
an
d A
C 0
8 (
1 C
red
it)
Tw
o-W
ay
Ele
ctr
on
ic C
om
mu
nic
ati
on
Par
tial
alig
nm
en
t. p
ract
ices
can
ch
oo
se t
o s
ho
w 3
of
the
5
req
uir
emen
ts
Yes –
Exclu
des R
ep
ort
s f
or
Cate
go
ry E
AC
04 (
Co
re)
C
lin
ical
Ad
vic
e D
ocu
men
tati
on
A
C 0
5 (
Co
re)
Clin
ical
Ad
vic
e
Do
cu
men
tati
on
✔
P
art
iall
y S
ha
red
**
AC
05 (
2 C
red
its)
C
on
tin
uit
y o
f M
ed
ical R
ec
ord
In
form
ati
on
AC
12
(2
Cre
dit
s)
Co
nti
nu
ity o
f M
ed
ical
Reco
rd In
form
ati
on
✔
Y
es
AC
06 (
1 C
red
it)
C
om
mu
nic
ate
an
d C
on
su
lt W
ith
T
reati
ng
Clin
icia
ns
N
o e
qu
ivale
nt
X
No
Pla
n a
nd
Ma
na
ge
Care
(P
M)
PM
01 (
Co
re)
Ris
k S
tatu
s Id
en
tifi
cati
on
C
M 0
1 (
Co
re)
Iden
tify
ing
Pati
en
ts f
or
Ca
re
Man
ag
em
en
t
Par
tial
alig
nm
en
t. P
CM
H r
equ
ires
a
form
aliz
ed p
roce
ss a
nd
pro
toco
l fo
r id
enti
fyin
g p
atie
nts
fo
r ca
re
man
agem
ent.
No
PM
02 (
2 C
red
its)
Co
mp
reh
en
siv
e R
isk
-Str
ati
ficati
on
C
M 0
3 (
2 C
red
its)
Co
mp
reh
en
siv
e R
isk
-S
trati
fic
ati
on
✔
N
o
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 7
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
PM
03 (
Co
re)
Wri
tten
Tre
atm
en
t P
lan
N
o e
qu
ivale
nt
X
No
PM
04 (
Co
re)
Tra
nsit
ion
to
Pri
ma
ry C
are
N
o e
qu
ivale
nt
X
No
PM
05 (
1 C
red
it)
Dis
cu
sse
s B
arr
ier
to T
reatm
en
t W
ith
th
e P
rim
ary
Care
C
lin
icia
n
CM
07 (
1 C
red
it)
Pati
en
t B
arr
iers
to
Go
als
P
art
ial
Alig
nm
en
t. C
onvers
ations
may p
rovid
e insig
hts
about
barr
iers
N
o
PM
06 (
Co
re)
Co
mm
un
icati
on
Pla
n f
or
Co
-M
an
ag
ed
Pati
en
ts
CC
12 (
1 C
red
it)
Co
-Man
ag
em
en
t A
rran
gem
en
ts
Part
ial
Alig
nm
en
t. P
CS
P P
M 0
6
expands b
eyon
d d
ocum
enta
tio
n o
f co-m
anagem
ent arr
ang
em
ents
by
esta
blis
hin
g a
com
munic
ation p
lan
fo
r th
ose p
atie
nts
.
No
PM
07 (
1 C
red
it)
Sh
are
d D
ec
isio
n-M
akin
g P
roc
ess
N
o e
qu
ivale
nt
X
No
PM
08 (
2 C
red
its)
Man
ag
em
en
t o
f S
eco
nd
Op
inio
ns
N
o e
qu
ivale
nt
X
No
PM
09 (
1 C
red
it)
Self
-Man
ag
em
en
t S
up
po
rt
No
eq
uiv
ale
nt
X
No
PM
10 (
1 C
red
it)
Pre
ven
tiv
e C
are
fo
r C
o-M
an
ag
ed
P
ati
en
ts
No
eq
uiv
ale
nt
X
No
PM
11 (
Co
re)
Sp
ecia
list'
s C
are
Pla
n
CM
04 (
Co
re),
CM
07 (
1 C
red
it),
CM
08 (
1
Cre
dit
) ✔
N
o
PM
12 (
Co
re)
Wri
tten
Care
Pla
n
CM
05 (
Co
re)
W
ritt
en
Care
Pla
ns
✔
N
o
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 8
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
PM
13 (
1 C
red
it)
Pla
n f
or
Man
ag
ing
Co
mp
lex
Med
icati
on
s
KM
17 (
1 C
red
it)
Med
icati
on
Resp
on
se
s
an
d B
arr
iers
Co
mp
lem
en
tary
Alig
nm
en
t:
Unders
tandin
g b
arr
iers
to
m
edic
ation a
dh
ere
nce
fro
m t
he
PC
P c
an s
up
port
and info
rm the
pla
n f
or
managin
g c
om
ple
x
medic
ations in th
e P
CS
P.
No
PM
14 (
1 C
red
it)
Op
ioid
Tre
atm
en
t A
gre
em
en
t N
o e
qu
ivale
nt
X
No
PM
15 (
1 C
red
it)
Th
e P
ati
en
t’s T
reatm
en
t T
eam
K
M 2
8 (
2 C
red
its)
Ca
se C
on
fere
nce
s
Part
ial ali
gn
men
t.
No
PM
16 (
1 C
red
it)
Co
nn
ects
to
Serv
ice
s in
th
e
Co
mm
un
ity
N
o e
qu
ivale
nt
X
No
PM
17 (
2 C
red
its)
Co
nn
ects
to
Fin
an
cia
l R
eso
urc
es
C
C 1
3 (
2 C
red
its)
Tre
atm
en
t O
pti
on
s a
nd
Co
sts
P
art
ial ali
gn
men
t.
No
PM
18 (
2 C
red
its)
Ob
tain
ing
Fin
an
cia
l A
ssis
tan
ce
N
o e
qu
ivale
nt
X
No
Co
ord
ina
tin
g C
are
an
d C
are
Tra
ns
itio
ns
(C
C)
CC
01 (
Co
re)
Info
rmin
g W
hen
R
efe
rrin
g
No
eq
uiv
ale
nt
X
No
CC
02 (
1 C
red
it)
Co
nsu
ltati
on
Wh
en
Refe
rrin
g
No
eq
uiv
ale
nt
X
No
CC
03 (
Co
re)
Seco
nd
ary
Refe
rral M
an
ag
em
en
t C
C 0
4 (
Co
re)
Refe
rral M
an
ag
em
en
t ✔
P
art
iall
y S
ha
red
**
CC
04 (
1 C
red
it)
No
tifi
cati
on
of
Se
co
nd
ary
Refe
rral
Resu
lts
N
o e
qu
ivale
nt
X
No
CC
05 (
Co
re)
Dia
gn
osti
c T
est
Man
ag
em
en
t C
C 0
1 (
Co
re)
Lab
an
d Im
ag
ing
Test
Man
ag
em
en
t ✔
P
art
iall
y S
ha
red
**
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 9
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
CC
06 (
2 C
red
its)
Lab
an
d Im
ag
ing
Ap
pro
pri
ate
nes
s
CC
03 (
2 C
red
its)
A
pp
rop
riate
Use f
or
Lab
s a
nd
Im
ag
ing
✔
N
o
CC
07 (
1 C
red
it)
Iden
tify
ing
Un
pla
nn
ed
Ho
sp
ital an
d
ED
Vis
its
CC
14 (
Co
re)
Id
en
tify
ing
Un
pla
nn
ed
Ho
sp
ital an
d E
D
Vis
its
✔
P
art
iall
y S
ha
red
**
CC
08 (
Co
re)
Sh
ari
ng
Clin
ical In
form
ati
on
C
C 1
5 (
Co
re)
Sh
ari
ng
Clin
ical In
form
ati
on
✔
P
art
iall
y S
ha
red
**
CC
09 (
Co
re)
Po
st-
Ho
sp
ital/
ED
Vis
it F
oll
ow
-Up
C
C 1
6 (
Co
re)
Po
st-
Ho
sp
ital/
ED
vis
it F
oll
ow
-Up
✔
P
art
iall
y S
ha
red
**
CC
10 (
2 C
red
its)
Aft
er
Ho
urs
Acu
te C
are
C
oo
rdin
ati
on
CC
17 (
1 C
red
it)
A
cu
te C
are
Aft
er
Ho
urs
Co
ord
inati
on
✔
P
art
iall
y S
ha
red
**
CC
11 (
1 C
red
it)
Info
rmati
on
Ex
ch
an
ge D
uri
ng
H
osp
italizati
on
CC
18 (
1 C
red
it)
Info
rmati
on
Ex
ch
an
ge d
uri
ng
H
osp
italizati
on
✔
P
art
iall
y S
ha
red
**
CC
12 (
1 C
red
it)
Pati
en
t D
isch
arg
e S
um
mari
es
C
C 1
9 (
1 C
red
it)
P
ati
en
t D
isch
arg
e S
um
mari
es
✔
P
art
iall
y S
ha
red
**
CC
13 (
Max
imu
m 3
Cre
dit
s)
Exte
rnal
Ele
ctr
on
ic E
xch
an
ge o
f In
form
ati
on
CC
21
(M
axim
um
3 C
red
its)
Exte
rnal
Ele
ctr
on
ic E
xch
an
ge o
f In
form
ati
on
✔
Y
es
Pe
rfo
rma
nce
Me
as
ure
me
nt
an
d Q
ua
lity
Me
as
ure
me
nt
(QI)
QI 01 (
Co
re)
Measu
re P
erf
orm
an
ce
Q
I 01, 0
2, 0
3,
04
(A
ll C
ore
) P
art
ial ali
gn
men
t. P
CS
P p
ractices
subm
it 2
clin
ical qua
lity m
easure
s
No
QI 02 (
1 C
red
it)
Valid
ate
d P
ati
en
t E
xp
eri
en
ce S
urv
ey
Use
QI 06 (
1 C
red
it)
Valid
ate
d P
ati
en
t E
xp
eri
en
ce S
urv
ey U
se
✔
N
o
QI 03 (
Co
re)
Go
als
an
d A
cti
on
s t
o Im
pro
ve
Q
I 08, 0
9, 1
0,
11
(A
ll C
ore
) ✔
N
o
QI 04 (
2 C
red
its)
Imp
rov
ed
P
erf
orm
an
ce
Q
I 12 (
2 C
red
its)
Im
pro
ved
Pe
rfo
rman
ce
✔
N
o
NC
QA
PC
SP
to P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ned
: ✔
No
Eq
uiv
ale
nt:
X
F
or
Colu
mn 4
, E
vid
ence S
hare
d W
ith P
CM
H:
**
Docum
ente
d p
rocesses m
ay b
e s
hare
d,
but
all
oth
er
evid
ence m
ust
be s
ite-s
pe
cific
. January
29,
20
19
pa
ge 1
0
PC
SP
(2
01
9 E
dit
ion
) P
CM
H (
20
17
Ed
itio
n)
Ali
gn
me
nt
No
tes
S
ha
red
Cre
dit
Op
tio
n W
ith
P
CM
H
QI 05 (
Maxim
um
2 C
red
its
) H
ealt
h D
isp
ari
ties A
sse
ss
men
t Q
I 05 (
1 C
red
it)
H
ealt
h D
isp
ari
ties A
sse
ss
men
t
Part
ial ali
gn
men
t. P
ractice
s m
ust
assess f
or
both
clin
ical qu
alit
y a
nd
patient
experi
ence m
easure
s in
PC
MH
.
No
QI 06 (
2 C
red
its)
Vu
lnera
ble
Pati
en
t F
eed
back
Q
I 07 (
2 C
red
its)
V
uln
era
ble
Pati
en
t F
eed
back
✔
N
o
QI 07 (
2 C
red
its)
Go
als
an
d A
cti
on
s
to Im
pro
ve D
isp
ari
ties i
n
Care
/Se
rvic
e
QI 13 (
1 C
red
it)
Go
als
an
d A
cti
on
s t
o Im
pro
ve D
isp
ari
ties
in C
are
/Serv
ice
✔
N
o
QI 08 (
2 C
red
its)
Imp
rov
ed
P
erf
orm
an
ce f
or
Dis
pari
ties in
Care
o
r S
erv
ice
QI 14 (
2 C
red
its)
Im
pro
ved
Pe
rfo
rman
ce f
or
Dis
pari
tie
s in
C
are
/Se
rvic
e
✔
No
QI 09 (
Co
re)
Rep
ort
ing
Perf
orm
an
ce in
th
e
Pra
cti
ce
QI 15 (
Co
re)
R
ep
ort
ing
Perf
orm
an
ce w
ith
in t
he P
racti
ce
✔
P
art
iall
y S
ha
red
**
QI 10 (
1 C
red
it)
Rep
ort
ing
P
erf
orm
an
ce P
ub
licly
or
Wit
h
Pati
en
ts
QI 16 (
1 C
red
it)
R
ep
ort
ing
Perf
orm
an
ce P
ub
licly
or
wit
h
Pati
en
ts
✔
Part
iall
y S
ha
red
**
QI 11 (
2 C
red
its)
Pati
en
t/F
am
ily/C
are
giv
er
Inv
olv
em
en
t in
Qu
ality
Im
pro
vem
en
t
QI 17
(2 C
red
its)
Pati
en
t/F
am
ily/C
are
giv
er
Inv
olv
em
en
t in
Qu
ality
Im
pro
vem
en
t ✔
N
o
QI 12 (
1 C
red
it)
Ele
ctr
on
ic S
ub
mis
sio
n o
f M
easu
res
Q
I 18
(2 C
red
its)
Rep
ort
ing
Perf
orm
an
ce
Measu
res t
o M
ed
icare
/Med
icaid
P
art
ial alig
nm
en
t.
No
QI 13 (
Maxim
um
2 C
red
its
) V
alu
e-B
ased
Pa
ym
en
t A
rran
gem
en
ts
QI 19
(M
axim
um
2 C
red
its
) V
alu
e-B
ased
C
on
tract
Ag
reem
en
ts
✔
Yes
Pa
tie
nt-
Ce
nte
red
On
co
logy M
ed
ica
l H
om
e
NC
QA
Oncolo
gy M
edic
al H
om
e to P
CM
H
Cro
ssw
alk
Ja
nu
ary
22
, 20
19
pa
ge
1
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r E
vid
ence
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
.
The t
ab
le b
elo
w c
om
pa
res N
CQ
A’s
Patien
t-C
ente
red O
nco
logy M
ed
ical H
om
e s
tanda
rds (
201
9 e
ditio
n)
with
the P
CM
H
(201
7 e
ditio
n)
pro
gra
m r
equire
men
ts.
Read
ing the
Colu
mn
s:
•
Alig
nm
en
t N
ote
s:
Com
pare
s s
pecific
Oncolo
gy M
edic
al H
om
e c
rite
ria
to P
CM
H c
rite
ria
an
d ide
ntifie
s ite
ms that
are
the s
am
e o
r sim
ilar
and n
ote
s d
iffe
rences.
The k
ey b
elo
w e
xpla
ins th
e s
ym
bols
.
•
Sh
are
d C
red
it O
pti
on
Wit
h P
CM
H:
Multi-
site o
rganiz
atio
ns s
eekin
g the
Onco
logy M
ed
ical H
om
e w
ith
exis
tin
g o
r co
ncurr
ent P
CM
H r
eco
gnitio
n m
ay s
tream
line
their
recogn
itio
n b
y s
ha
ring
crite
ria b
etw
een
th
e p
rogra
ms.
This
co
lum
n d
en
ote
s the s
pecific
sh
are
d c
red
it a
lignm
en
t.
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
Team
-Bas
ed
Care
an
d P
racti
ce O
rgan
izati
on
(T
C)
TC
01
(C
ore
)
Tra
nsfo
rmati
on
Le
ad
s
TC
01
(C
ore
) P
CM
H T
ran
sfo
rma
tio
n L
ea
ds
✔
No
TC
02
(C
ore
)
Str
uc
ture
an
d S
taff
Re
sp
on
sib
ilit
ies
TC
02
(C
ore
)
Str
uc
ture
an
d S
taff
Res
po
ns
ibilit
ies
✔
No
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
2
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
TC
03
(1
Cre
dit
)
Co
lla
bo
rati
on
wit
h t
he
Me
dic
al
Ne
igh
bo
rho
od
TC
03
(1
Cre
dit
) E
xte
rna
l P
CM
H C
olla
bo
rati
on
s
✔
No
TC
04
(2
Cre
dit
s)
Pa
tie
nts
/Fam
ilie
s/C
are
giv
ers
In
vo
lve
me
nt
in G
ove
rna
nc
e
TC
04
(2
Cre
dit
s)
Pa
tie
nts
/Fam
ilie
s/C
are
giv
ers
In
vo
lve
me
nt
in G
ove
rna
nc
e
✔
No
TC
05
(2
Cre
dit
s)
C
ert
ifie
d E
HR
Sys
tem
T
C 0
5 (
2 C
red
its
) C
ert
ifie
d E
HR
Sys
tem
✔
Y
es
TC
06
(C
ore
)
Ind
ivid
ua
l P
ati
en
t C
are
M
ee
tin
gs
/Co
mm
un
ica
tio
n
TC
06
(C
ore
) In
div
idu
al P
ati
en
t C
are
M
ee
tin
gs
/Co
mm
un
ica
tio
n
✔
No
TC
07
(C
ore
)
Sta
ff In
vo
lve
me
nt
in Q
ua
lity
Im
pro
ve
me
nt
TC
07
(C
ore
) S
taff
In
vo
lve
me
nt
in Q
ua
lity
Im
pro
ve
me
nt
✔
No
TC
08
(C
ore
)
Sp
ec
ialt
y P
rac
tic
e In
form
ati
on
T
C 0
9 (
Co
re)
Me
dic
al H
om
e In
form
ati
on
✔
N
o
Init
ial
Refe
rral
Man
ag
em
en
t (R
M)
RM
01
(C
ore
)
Se
ttin
g E
xp
ec
tati
on
s W
ith
Re
ferr
ing
C
lin
icia
ns
CC
08
(1
Cre
dit
) S
pe
cia
lis
t R
efe
rra
l E
xp
ec
tati
on
s
✔
No
RM
02
(1
Cre
dit
)
Ag
ree
me
nts
Wit
h R
efe
rrin
g C
lin
icia
ns
C
C 0
8 (
1 C
red
it)
Sp
ec
ialis
t R
efe
rra
l E
xp
ec
tati
on
s
Co
mp
lem
en
tary
alig
nm
en
t. A
n
ag
ree
men
t fo
rme
d b
etw
een
a r
efe
rrin
g
PC
MH
or
a r
efe
rrin
g s
pe
cia
list
co
uld
b
e u
se
d to
me
et P
CM
H C
C 0
8 a
nd
P
CS
P R
M 0
2
No
RM
03
(C
ore
) C
om
mu
nic
ati
ng
Re
ferr
al R
eq
ue
sts
N
o e
qu
iva
len
t X
N
o
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
3
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
RM
04
(C
ore
) V
eri
fie
s R
ece
ipt
of
Info
rma
tio
n
CC
04
(C
ore
) A
an
d C
R
efe
rra
l M
an
ag
em
en
t
Co
mp
lem
en
tary
Alig
nm
en
t:
Re
ce
ivin
g c
om
ple
te in
form
atio
n fro
m
the
PC
MH
su
pp
ort
s t
he
re
ferr
al
ma
na
ge
men
t p
roce
ss in
PC
SP
.
No
RM
05
(C
ore
)
Ga
the
rin
g In
form
ati
on
No
t In
itia
lly
Re
ce
ive
d
No
eq
uiv
ale
nt
X
No
RM
06
(C
ore
) F
ollo
w-U
p A
fte
r M
isse
d
Ap
po
intm
en
ts a
nd
Ca
nce
lla
tio
ns
No
eq
uiv
ale
nt
X
No
RM
07
(C
ore
) R
es
po
ns
e t
o P
rim
ary
Ca
re a
nd
Refe
rrin
g
Cli
nic
ian
s
CC
11
(1
Cre
dit
) R
efe
rra
l M
on
ito
rin
g
Co
mp
lem
en
tary
Alig
nm
en
t:
Pro
vid
ing
co
mp
lete
in
form
atio
n
su
pp
ort
s t
he
re
ferr
al m
on
itorin
g
pro
ce
ss in
PC
MH
.
No
RM
08
(C
ore
) D
oc
um
en
tin
g P
rim
ary
Ca
re C
lin
icia
n
No
eq
uiv
ale
nt
X
No
RM
09
(1
Cre
dit
) C
om
mu
nic
ate
s t
he
Im
po
rta
nc
e o
f F
ollo
w-U
p W
ith
Pri
ma
ry
Ca
re
No
eq
uiv
ale
nt
X
No
RM
10
(1
Cre
dit
)
Co
nn
ec
tin
g P
ati
en
ts W
ith
Pri
ma
ry C
are
N
o e
qu
iva
len
t X
N
o
RM
11
(C
ore
) C
on
tacti
ng
th
e P
rim
ary
Ca
re
Cli
nic
ian
Pri
or
to T
reatm
en
t N
o e
qu
iva
len
t X
N
o
Kn
ow
ing
an
d M
an
ag
ing
Yo
ur
Pati
en
ts (
KM
)
KM
01
(C
ore
)
Pa
tie
nt-
Sp
ecia
lis
t R
ela
tio
ns
hip
C
C 1
2 (
1 C
red
it)
Co
-Man
ag
em
en
t A
rra
ng
em
en
ts
Pa
rtia
l A
lig
nm
en
t.
No
KM
02
(C
ore
)
Me
dic
al H
isto
ry a
nd
Pro
ble
m L
ist
Do
cu
men
tati
on
KM
01
(C
ore
)
Pro
ble
m L
ists
an
d K
M 0
2 (
Co
re)
A
Me
dic
al h
isto
ry o
f p
ati
en
t a
nd
fa
mily
✔
No
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
4
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
KM
03
(1
Cre
dit
)
Pre
do
min
an
t C
on
dit
ion
s a
nd
Co
nc
ern
s
KM
06
(1
Cre
dit
) P
red
om
ina
nt
Co
nd
itio
ns
an
d
Co
nc
ern
s
✔
No
KM
04
(C
ore
) O
nc
olo
gy C
om
pre
he
ns
ive
He
alt
h
As
se
ss
men
t
KM
02
(C
ore
) B
, C
, D
, E
, I
Co
mp
reh
en
siv
e H
ea
lth
As
se
ss
me
nt
Pa
rtia
l a
lig
nm
en
t. P
C-O
MH
als
o
assesse
s p
ain
asse
ssm
ent/fu
nctio
na
l a
ssessm
en
t (P
C-O
MH
KM
04
E)
an
d
pa
tie
nt p
refe
ren
ce
s a
nd
pers
on
al
he
alth
goa
ls (
KM
04
F)
an
d ite
ms
sp
ecific
ally
re
late
d to
on
co
log
y c
are
a
nd
tre
atm
ent. (
KM
04
H-M
).
Pa
rtia
lly S
ha
red
**
KM
05
(C
ore
) B
eh
avio
ral H
ea
lth
Sc
ree
nin
gs
K
M 0
3 (
Co
re),
KM
04
(1
Cre
dit
) A
-G
Pa
rtia
l alig
nm
en
t. P
CS
P in
clu
des
co
gn
itiv
e im
pa
irm
en
t (K
M 0
5 I)
an
d
dis
tress (
KM
05
J).
P
art
ially S
ha
red
**
KM
06
(C
ore
) D
ive
rsit
y
KM
09
(C
ore
) D
ive
rsit
y
✔
No
KM
07
(C
ore
) L
an
gu
ag
e
KM
10
(C
ore
) L
an
gu
ag
e
✔
No
KM
08
(2
Cre
dit
s)
Sta
ff C
ult
ura
l C
om
pete
nce a
nd
He
alt
h L
ite
rac
y S
kil
ls
KM
11
Po
pu
lati
on
Ne
ed
s
✔
No
KM
09
(C
ore
)
Do
cu
men
t an
d R
eco
nc
ile
Me
dic
ati
on
s
KM
14
(C
ore
) M
ed
icati
on
R
ec
on
cilia
tio
n a
nd
KM
15
(C
ore
) M
ed
icati
on
Lis
ts
✔
No
KM
10
(C
ore
)
New
Pre
sc
rip
tio
n E
du
cati
on
K
M 1
6 (
1 C
red
it)
New
Pre
sc
rip
tio
n
Ed
uc
ati
on
✔
N
o
KM
11
(C
ore
)
Ma
na
gin
g M
ed
ica
tio
n W
ith
th
e C
are
Te
am
N
o e
qu
iva
len
t X
N
o
KM
12
(1
Cre
dit
)
Me
dic
ati
on
Re
sp
on
ses
an
d B
arr
iers
K
M 1
7 (
1 C
red
it)
Me
dic
ati
on
R
es
po
ns
es
an
d B
arr
iers
✔
N
o
KM
13
(1
Cre
dit
)
Co
ntr
oll
ed
Su
bs
tan
ce
Da
tab
as
e R
evie
w
KM
18
(1
Cre
dit
) C
on
tro
lle
d S
ub
sta
nce
D
ata
bas
e R
evie
w
✔
Ye
s
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
5
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
KM
14
(2
Cre
dit
s)
P
res
cri
pti
on
Cla
ims
Da
ta
KM
19
(2
Cre
dit
s)
Pre
sc
rip
tio
n C
laim
s
Da
ta
✔
Ye
s
KM
15
(C
ore
) P
roa
cti
ve
Re
min
de
r
KM
12
(C
ore
) P
roa
cti
ve
Ou
tre
ac
h
Pa
rtia
l alig
nm
en
t. P
CM
H s
pecifie
s
tha
t re
min
de
rs m
ust
be
acro
ss s
pe
cific
ca
tego
ries a
nd
re
qu
ire
s a
t le
ast 3
p
roactive
re
min
de
rs.
No
KM
16
(1
Cre
dit
)
Ad
dit
ion
al P
roa
cti
ve
Re
min
de
rs
No
KM
17
(C
ore
)
Cli
nic
al D
ec
isio
n S
up
po
rt
KM
20
(C
ore
) C
lin
ica
l D
ec
isio
n
Su
pp
ort
Pa
rtia
l alig
nm
en
t. P
CM
H s
pecifie
s
tha
t clin
ica
l de
cis
ion
su
pp
ort
mu
st
de
mo
nstr
ate
at le
ast 4
diffe
ren
t co
nd
itio
ns/issu
es.
No
KM
18
(C
ore
)
Ad
dit
ion
al C
lin
ica
l D
ec
isio
n S
up
po
rts
No
KM
19
(C
ore
)
Pa
thw
ays
fo
r S
ym
pto
m M
an
ag
em
en
t N
o e
qu
iva
len
t X
N
o
KM
20
(2
Cre
dit
s)
E
xc
elle
nc
e in
Pe
rfo
rma
nc
e
KM
13
(2
Cre
dit
s)
E
xc
elle
nc
e in
Pe
rfo
rma
nc
e
✔
No
KM
21
(1
Cre
dit
)
Sh
are
d D
ec
isio
n-M
ak
ing
Aid
s
KM
24
(1
Cre
dit
) S
ha
red
De
cis
ion
-Mak
ing
Aid
s
✔
No
Pati
en
t-C
en
tere
d A
ccess a
nd
Co
nti
nu
ity (
AC
)
AC
01
(C
ore
)
Ac
ce
ss
fo
r U
rge
nt
Ne
ed
s
AC
01
(C
ore
) A
cc
es
s N
eed
s a
nd
P
refe
ren
ces
Par
tial
alig
nm
en
t. P
CSP
is s
pec
ific
to
u
rgen
t n
eed
s w
hile
PC
MH
ref
ers
to
bo
th r
ou
tin
e a
nd
urg
ent
app
oin
tmen
t ac
cess
.
No
AC
02
(C
ore
)
Tim
ely
Clin
ica
l A
dvic
e b
y T
ele
ph
on
e
AC
04
(C
ore
) T
ime
ly C
lin
ica
l A
dvic
e b
y
Te
lep
ho
ne
✔
Pa
rtia
lly S
ha
red
**
AC
03
(1
Cre
dit
)
Pa
tie
nt
Po
rta
l
AC
07
(1
Cre
dit
) E
lec
tro
nic
Pa
tie
nt
Re
qu
es
ts a
nd
AC
08
(1
Cre
dit
) T
wo
-W
ay E
lec
tro
nic
Co
mm
un
ica
tio
n
Par
tial
alig
nm
en
t. p
ract
ices
can
ch
oo
se t
o s
ho
w 3
of
the
5
req
uir
emen
ts
Ye
s –
Ex
clu
de
s R
ep
ort
s
for
Ca
teg
ory
E
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
6
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
AC
04
(C
ore
)
Cli
nic
al A
dvic
e D
ocu
me
nta
tio
n
AC
05
(C
ore
) C
lin
ica
l A
dv
ice
D
oc
um
en
tati
on
✔
P
art
ially S
ha
red
**
AC
05
(C
ore
)
Co
nti
nu
ity o
f M
ed
ica
l R
ec
ord
In
form
ati
on
A
C 1
2 (
2 C
red
its
) C
on
tin
uit
y o
f M
ed
ica
l R
ec
ord
In
form
ati
on
✔
Y
es
AC
06
(1
Cre
dit
)
Co
mm
un
icate
an
d C
on
su
lt W
ith
Tre
ati
ng
C
lin
icia
ns
No
eq
uiv
ale
nt
X
No
Pla
n a
nd
Man
ag
e C
are
(P
M)
PM
01
(C
ore
) R
isk
Sta
tus
Id
en
tifi
ca
tio
n
CM
01
(C
ore
) Id
en
tify
ing
Pa
tie
nts
fo
r C
are
Ma
na
ge
me
nt
Pa
rtia
l a
lig
nm
en
t. P
CM
H r
eq
uire
s a
fo
rma
lize
d p
rocess a
nd
pro
toco
l fo
r id
en
tify
ing
patie
nts
fo
r ca
re
ma
na
ge
men
t.
No
PM
02
(2
Cre
dit
s)
Co
mp
reh
en
siv
e R
isk
-Str
ati
fic
ati
on
C
M 0
3 (
2 C
red
its
) C
om
pre
he
ns
ive
R
isk
-Str
ati
fic
ati
on
✔
N
o
PM
03
(C
ore
) W
ritt
en
Tre
atm
en
t P
lan
N
o e
qu
iva
len
t X
N
o
PM
04
(C
ore
) T
ran
sit
ion
to
Pri
ma
ry C
are
N
o e
qu
iva
len
t X
N
o
PM
05
(1
Cre
dit
) D
isc
us
se
s B
arr
ier
to
Tre
atm
en
t W
ith
th
e P
rim
ary
Ca
re C
lin
icia
n
CM
07
(1
Cre
dit
) P
ati
en
t B
arr
iers
to
G
oa
ls
Pa
rtia
l A
lig
nm
en
t. C
on
vers
ation
s m
ay
pro
vid
e insig
hts
ab
ou
t b
arr
iers
N
o
PM
06
(C
ore
) C
om
mu
nic
ati
on
Pla
n f
or
Co
-Ma
nag
ed
P
ati
en
ts
CC
12
(1
Cre
dit
) C
o-M
an
ag
em
en
t A
rra
ng
em
en
ts
Pa
rtia
l A
lig
nm
en
t. P
C-O
MH
PM
06
e
xp
an
ds b
eyo
nd
docu
me
nta
tio
n o
f co
-m
an
age
men
t a
rra
nge
me
nts
by
esta
blis
hin
g a
co
mm
un
ica
tio
n p
lan
fo
r th
ose
pa
tie
nts
.
No
PM
07
(C
ore
) S
ha
red
De
cis
ion
-Mak
ing
Pro
ce
ss
No
eq
uiv
ale
nt
X
No
PM
08
(2
Cre
dit
s)
Ma
na
ge
me
nt
of
Se
co
nd
Op
inio
ns
No
eq
uiv
ale
nt
X
No
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
7
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
PM
09
(1
Cre
dit
) S
elf
-Man
ag
em
en
t S
up
po
rt
No
eq
uiv
ale
nt
X
No
PM
10
(1
Cre
dit
) P
reve
nti
ve
Ca
re f
or
Co
-Ma
na
ged
Pa
tie
nts
N
o e
qu
iva
len
t X
N
o
PM
11
(C
ore
) S
pe
cia
lis
t's
Ca
re P
lan
C
M 0
4 (
Co
re),
CM
07
(1
Cre
dit
), C
M 0
8
(1 C
red
it)
✔
No
PM
12
(C
ore
) W
ritt
en
Ca
re P
lan
C
M 0
5 (
Co
re)
W
ritt
en
Ca
re P
lan
s
✔
No
PM
13
(1
Cre
dit
) P
lan
fo
r M
an
ag
ing
Co
mp
lex
Me
dic
ati
on
s
KM
17
(1
Cre
dit
) M
ed
ica
tio
n
Re
sp
on
ses
an
d B
arr
iers
Co
mp
lem
en
tary
Alig
nm
en
t:
Un
de
rsta
nd
ing
ba
rrie
rs t
o m
ed
ica
tio
n
ad
he
rence
fro
m th
e P
CP
ca
n s
upp
ort
a
nd
in
form
th
e p
lan
fo
r m
an
ag
ing
co
mp
lex m
edic
atio
ns in
th
e P
CS
P.
No
PM
14
(1
Cre
dit
) O
pio
id T
reatm
en
t A
gre
em
en
t N
o e
qu
iva
len
t X
N
o
PM
15
(1
Cre
dit
) T
he
Pa
tie
nt’
s T
rea
tme
nt
Te
am
K
M 2
8 (
2 C
red
its
) C
as
e C
on
fere
nc
es
Pa
rtia
l a
lig
nm
en
t.
No
PM
16
(C
ore
) C
on
ne
cts
to
Se
rvic
es
in
th
e C
om
mu
nit
y
No
eq
uiv
ale
nt
X
No
PM
17
(C
ore
) C
on
ne
cts
to
Fin
an
cia
l R
es
ou
rces
CC
13
(2
Cre
dit
s)
Tre
atm
en
t O
pti
on
s a
nd
Co
sts
P
art
ial a
lig
nm
en
t.
No
PM
18
(2
Cre
dit
s)
Ob
tain
ing
Fin
an
cia
l A
ss
ista
nc
e
No
eq
uiv
ale
nt
X
No
PM
19
(C
ore
)
Ch
em
oth
era
py P
rep
ara
tio
n
No
eq
uiv
ale
nt
X
No
PM
20
(C
ore
)
Ch
em
oth
era
py A
dm
inis
tra
tio
n
No
eq
uiv
ale
nt
X
No
Co
ord
inati
ng
Care
an
d C
are
Tra
nsit
ion
s (
CC
) C
C 0
1 (
Co
re)
Info
rmin
g W
he
n R
efe
rrin
g
No
eq
uiv
ale
nt
X
No
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
8
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
CC
02
(1
Cre
dit
) C
on
su
ltati
on
Wh
en
Re
ferr
ing
N
o e
qu
iva
len
t X
N
o
CC
03
(C
ore
) S
ec
on
dary
Re
ferr
al M
an
ag
em
en
t C
C 0
4 (
Co
re)
Re
ferr
al M
an
ag
em
en
t ✔
P
art
ially S
ha
red
**
CC
04
(1
Cre
dit
) N
oti
fic
ati
on
of
Se
co
nd
ary
Re
ferr
al
Re
su
lts
N
o e
qu
iva
len
t X
N
o
CC
05
(C
ore
) D
iag
no
sti
c T
es
t M
an
ag
em
en
t C
C 0
1 (
Co
re)
La
b a
nd
Im
ag
ing
Te
st
Ma
na
ge
me
nt
✔
Pa
rtia
lly S
ha
red
**
CC
06
(2
Cre
dit
s)
La
b a
nd
Im
ag
ing
Ap
pro
pri
ate
nes
s
CC
03
(2
Cre
dit
s)
A
pp
rop
ria
te U
se
fo
r L
ab
s a
nd
Im
ag
ing
✔
N
o
CC
07
(1
Cre
dit
) Id
en
tify
ing
Un
pla
nn
ed
Ho
sp
ita
l a
nd
ED
V
isit
s
CC
14
(C
ore
)
Ide
nti
fyin
g U
np
lan
ne
d H
os
pit
al a
nd
ED
V
isit
s
✔
Pa
rtia
lly S
ha
red
**
CC
08
(C
ore
) S
ha
rin
g C
lin
ica
l In
form
ati
on
C
C 1
5 (
Co
re)
Sh
ari
ng
Cli
nic
al
Info
rma
tio
n
✔
Pa
rtia
lly S
ha
red
**
CC
09
(C
ore
) P
os
t-H
os
pit
al/E
D V
isit
Fo
llo
w-U
p
CC
16
(C
ore
) P
os
t-H
os
pit
al/E
D v
isit
Fo
llo
w-U
p
✔
Pa
rtia
lly S
ha
red
**
CC
10
(2
Cre
dit
s)
Aft
er
Ho
urs
Ac
ute
Ca
re C
oo
rdin
ati
on
C
C 1
7 (
1 C
red
it)
A
cu
te C
are
Aft
er
Ho
urs
Co
ord
ina
tio
n
✔
Pa
rtia
lly S
ha
red
**
CC
11
(1
Cre
dit
) In
form
ati
on
Ex
ch
an
ge
Du
rin
g
Ho
sp
ita
liza
tio
n
CC
18
(1
Cre
dit
) In
form
ati
on
Ex
ch
an
ge
du
rin
g
Ho
sp
ita
liza
tio
n
✔
Pa
rtia
lly S
ha
red
**
CC
12
(1
Cre
dit
) P
ati
en
t D
isch
arg
e S
um
ma
rie
s
CC
19
(1
Cre
dit
)
Pa
tie
nt
Dis
ch
arg
e S
um
ma
rie
s
✔
Pa
rtia
lly S
ha
red
**
CC
13
(M
ax
imu
m 3
Cre
dit
s)
Ex
tern
al E
lec
tro
nic
Exc
ha
ng
e o
f In
form
ati
on
CC
21
(M
ax
imu
m 3
Cre
dit
s)
Exte
rna
l E
lec
tro
nic
Ex
ch
an
ge
of
Info
rmati
on
✔
Y
es
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
. Ja
nu
ary
22
, 20
19
pa
ge
9
On
co
log
y M
ed
ical
Ho
me
(
2019
Ed
itio
n)
PC
MH
(2017 E
dit
ion
) A
lig
nm
en
t N
ote
s
Sh
are
d C
red
it O
pti
on
W
ith
PC
MH
Perf
orm
an
ce M
easu
rem
en
t an
d Q
uality
Measu
rem
en
t (Q
I)
QI 0
1 (
Co
re)
Me
as
ure
Pe
rfo
rma
nce
QI 0
1, 0
2, 0
3, 0
4 (
All C
ore
) P
art
ial
ali
gn
men
t. P
CS
P p
ractices
su
bm
it 2
clin
ical qu
alit
y m
easure
s
No
QI 0
2 (
1 C
red
it)
Va
lid
ate
d P
ati
en
t E
xp
eri
en
ce
Su
rve
y U
se
QI 0
6 (
1 C
red
it)
Va
lid
ate
d P
ati
en
t E
xp
eri
en
ce
Su
rve
y
Us
e
✔
No
QI 0
3 (
Co
re)
Go
als
an
d A
cti
on
s t
o Im
pro
ve
Q
I 0
8, 0
9, 1
0, 1
1 (
All C
ore
) ✔
N
o
QI 0
4 (
2 C
red
its
) Im
pro
ve
d P
erf
orm
an
ce
QI 1
2 (
2 C
red
its
) Im
pro
ve
d P
erf
orm
an
ce
✔
No
QI 0
5 (
Ma
xim
um
2 C
red
its
) H
ea
lth
Dis
pari
tie
s A
ss
ess
me
nt
QI 0
5 (
1 C
red
it)
H
ea
lth
Dis
pari
tie
s A
ss
ess
me
nt
Pa
rtia
l a
lig
nm
en
t. P
ractice
s m
ust
assess for
both
clin
ica
l q
ualit
y a
nd
p
atie
nt e
xp
erie
nce
me
asu
res in
P
CM
H.
No
QI 0
6 (
2 C
red
its
) V
uln
era
ble
Pa
tie
nt
Fe
ed
ba
ck
QI 0
7 (
2 C
red
its
)
Vu
lne
rab
le P
ati
en
t F
ee
db
ac
k
✔
No
QI 0
7 (
2 C
red
its
) G
oa
ls a
nd
Acti
on
s t
o
Imp
rove
Dis
pa
riti
es
in
Ca
re/S
erv
ice
QI 1
3 (
1 C
red
it)
Go
als
an
d A
cti
on
s t
o Im
pro
ve
D
isp
ari
tie
s in
Ca
re/S
erv
ice
✔
No
QI 0
8 (
2 C
red
its
) Im
pro
ve
d P
erf
orm
an
ce
fo
r D
isp
ari
tie
s in
Ca
re o
r S
erv
ice
QI 1
4 (
2 C
red
its
)
Imp
rove
d P
erf
orm
an
ce
fo
r D
isp
ari
ties
in
Ca
re/S
erv
ice
✔
No
QI 0
9 (
Co
re)
Re
po
rtin
g P
erf
orm
an
ce
in
th
e P
racti
ce
QI 1
5 (
Co
re)
R
ep
ort
ing
Pe
rfo
rman
ce
wit
hin
th
e
Pra
cti
ce
✔
Pa
rtia
lly S
ha
red
**
QI 1
0 (
1 C
red
it)
Re
po
rtin
g P
erf
orm
an
ce
P
ub
lic
ly o
r W
ith
Pa
tien
ts
QI 1
6 (
1 C
red
it)
R
ep
ort
ing
Pe
rfo
rman
ce
Pu
blic
ly o
r w
ith
Pa
tie
nts
✔
P
art
ially S
ha
red
**
NC
QA
On
co
logy M
edic
al H
om
e t
o P
CM
H C
rossw
alk
Ke
y:
Fu
lly A
lig
ne
d: ✔
No
Eq
uiv
ale
nt:
X
Fo
r C
olu
mn
4, E
vid
en
ce
Sh
are
d W
ith
PC
MH
:
** D
ocu
men
ted
pro
ce
sse
s m
ay b
e s
hare
d, b
ut a
ll o
the
r e
vid
ence
mu
st
be
site
-sp
ecific
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No
Patient-Centered Oncology Medical Home
NCQA Oncology Medical Home to PCSP Crosswalk
January 22, 2019 page 1
The Oncology Medical Home Program and the Patient-Centered Specialty Program share the same
foundational criteria. The Oncology Medical Home identifies 9 PCSP electives as core for oncology
(equating to 11 elective credits in the PCSP program) and introduces 2 core and 1 elective criteria specific
to oncology. The table below shows the differences in requirements between the two programs. To
achieve recognition under Oncology Medical Home, practices must:
1. Meet all 49 core criteria in the program and
2. Earn 9 credits in elective criteria across any of 7 concepts.
This ensures a minimum set of capabilities and gives practices the flexibility to focus on activities that are both
meaningful to their patient population and feasible to accomplish given the resources available at the practice
and within their community.
Criteria Name Oncology Medical
Home PCSP
KM 04: Oncology Comprehensive Health Assessment* Core 1 Credit
KM 05: Behavioral Health Screenings Core 1 Credit
KM 10: New Prescription Education Core 1 Credit
KM 18: Additional Clinical Decision Supports Core 1 Credit
KM 19: Pathways for Symptom Management Core 1 Credit
AC 05: Continuity of Medical Record Information Core 2 Credits
PM 07: Shared Decision-Making Process Core 1 Credit
PM 16: Connects to Services in the Community Core 1 Credit
PM 17: Connects to Financial Resources Core 2 Credits
PM 19: Chemotherapy Preparation Core NA
PM 20: Chemotherapy Administration Core NA
QI 14: Report Standardized Core Oncology Measures 2 Credits NA
*The Oncology Medical Home program has additional requirements that focus specifically on oncology care and treatment (KM 04 H-M).