PCMH 2014 Standards and Guidelines

28NCQA Patient-Centered Medical Home 2014November 16, 2015

PCMH 1: Patient-Centered AccessPCMH 1: Patient-Centered Access2910.00 pointsThe practice provides access to team-based care for both routine and urgent needs ofpatients/families/caregivers at all times.Element A: Patient-Centered Appointment Access (MUST-PASS)4.50 pointsThe practice has a written process and defined standards for providingaccess to appointments, and regularly assesses its performance on:YesNo1. Providing same-day appointments for routine and urgent care.(CRITICAL FACTOR) 2. Providing routine and urgent-care appointments outside regularbusiness 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. 100%The practicemeets 5-6factors(includingfactor 1)ScoringExplanation75%The practicemeets 3-4factors(includingfactor 1)50%The practicemeets 2factors(includingfactor 1)25%The practicemeets 1 factor(includingfactor 1)0%The practicemeets 0factorsMUST-PASS elements are considered the basic building blocks of a patientcentered medical home. Practices must earn a score of 50% or higher. All sixmust-pass elements are required for recognition.The practice has a written policy for making appointments available for both urgentand routine issues. The policy states time requirements and defines “routine” and“urgent.” For example, the practice has a policy that urgent issues are seenimmediately and routine visits (e.g., new-patient physicals, return-visit exams tomonitor mild acute and chronic conditions) are scheduled within seven days.The practice triages patients to determine the urgency of a request for a same-dayappointment; triage considers patient care need and preference.Patients access the clinician and care team for routine and urgent care needs byoffice visit, by telephone or through secure electronic messaging.Factor 1: Factor 1 is a critical factor and must be met for practices to receive ascore on this element. Since this is also a must pass element, failure to meetfactor 1 will result in denial of recognition.The practice reserves time for same-day appointments (also referred to as “same-dayscheduling”) for routine and urgent care based on patient preference and need.Adding ad hoc or unscheduled appointments to a full day of scheduled appointmentsdoes not meet the requirement.The practice has a process for scheduling same-day visits for patients with routineand urgent needs, and monitors use of same-day appointments to ensure thatpatients are able to use this feature.November 16, 2015NCQA Patient-Centered Medical Home 2014

30PCMH 1: Patient-Centered AccessWalk-in hours are an approach to patient access that allows the patient to come into thepractice without prior notice. A practice can provide walk-in hours in addition to sameday appointments; however, providing walk-in hours alone does not meet therequirement for providing same day appointments.Factor 2: The practice schedules appointments outside its typical daytime schedule.For example a practice may open for appointments at 7 a.m. or remain open until 8 p.m.on certain days or it may be open two Saturdays each month.Providing extended access does not include: Offering daytime appointments when the practice would otherwise be closed forlunch (on some or most days). Offering daytime appointments when the practice would otherwise close early(e.g., a weekday afternoon or holiday).The practice is expected to provide appointment times that meet the needs of itspatients; for example, offering Saturday appointment times for both routine and urgentcare to allow patients who work during the week to obtain annual exams or be seen foran upper respiratory infection.Practices are encouraged to first assess the needs of their patients for appointmentsoutside normal business hours and then to evaluate if these appointment times meetthe needs of the patients.If the practice is not able to provide care beyond regular office hours (e.g., a smallpractice with limited staffing), it may arrange for patients to schedule appointments withother (non-ER, non-urgent care) facilities or clinicians. However, if the practice uses anurgent care center for urgent and routine appointments outside regular business hourswithin the same health system or has established arrangements with an urgent carecenter within the community that has access to the patient record, would be acceptable.Suggesting that patients locate the nearest ER or urgent care facility that has noarrangement or connection with the practice does not meet the intent of thisrequirement.Factor 3: An alternative type of clinical encounter is a scheduled meeting, such as abillable visit, between patient and clinician using a mode of real-time communication inlieu of a traditional one-on-one in-person office visit; for example, standalonecommunication or a combination of telephone, video chat and secure instantmessaging. Group visits or shared medical appointments, where the patient is one ofseveral patients scheduled for care at the same time also qualifies as an “alternativetype of clinical encounter.”Unscheduled alternative clinical encounters, including clinical advice by telephone andsecure electronic communication (e.g., electronic message, Web site) during officehours do not meet the requirement. An appointment with an alternative type of clinician(e.g., diabetic counselor) does not meet the requirement.Factor 4: The practice has standards for appointment availability. Availability standardsmay be established and measured for a variety of appointment types, including urgentcare, new patient physicals, routine exams and return-visit exams or the practice mayset a single standard across all appointment types (e.g. open access for all). Onecommon approach to measuring appointment availability against standards is todetermine the third next available appointment for each appointment type, with an openaccess goal of zero days (same-day availability).NCQA Patient-Centered Medical Home 2014November 16, 2015

PCMH 1: Patient-Centered Access31The third next available appointment measures the length of time from when a patientcontacts the practice to request an appointment, to the third next available appointmenton the clinician’s schedule. The Institute for Healthcare Improvement (IHI) identifiedthird next available appointment tracking as “a more sensitive reflection of trueappointment availability.” IHI has set a goal of zero days for primary hirdNextAvailableAppointment.aspx).A clinician’s panel may be closed, but appointment availability may not be based onpayer.Factor 5: To provide consistent access and help understand true demand, practicesmonitor no-show rates. No-show rates may be calculated by taking the number ofpatients who did not keep their pre-scheduled appointments during a specific period oftime (i.e. a session or a day) divided by the number of patients who were pre-scheduledto come to the center for appointments during the same period of time (Primary CareDevelopment Corporation).Factor 6: To expand access and capacity, the practice uses information gathered fromreports in factors 1–5 to identify opportunities to improve access.The practice may participate in or implement a rapid-cycle improvement process, suchas Plan-Do-Study-Act (PDSA), that represents a commitment to ongoing qualityimprovement and goes beyond setting goals and taking action.Resource: One resource for the PDSA cycle is the Institute for Healthcare Improvement(IHI): entMethods/HowToImprove/.DocumentationFor all factors that require a documented process for staff, the documented processfor staff includes a date of implementation or revision and has been in place for at leastthree months prior to submitting the PCMH 2014 Survey Tool.Factor 1: NCQA reviews a documented process for scheduling same-day appointmentsthat includes defining their appointment types. NCQA reviews a report with at least fivedays of data, showing the availability and use of same-day appointments for both urgentand routine care.Factor 2: NCQA reviews a documented process for staff to follow for arranging routineand urgent appointment access during extended hours with other practices or cliniciansand provides a report showing extended hours availability or materials provided topatients demonstrating that the practice provides regular extended hours. NCQAreviews a report with at least five days of data, showing availability and use ofappointments outside the normal hours of operation. A process for arranging extendedhours access is not required if the practice site has regular extended hours.Factor 3: NCQA reviews a documented process for arranging appointments foralternative types of encounters (e.g., telephone, group visits, video chat). NCQAreviews a report of encounter types and dates that includes frequency of scheduledalternative encounter types in a recent 30-calendar-day period.Ad hoc telephone or e-mail exchanges do not meet the requirement.Factor 4: NCQA reviews a documented process defining the practice’s standards fortimely appointment availability (e.g., within 14 calendar days for physicals, within 2 daysfor follow-up care, same day for urgent care needs) and for monitoring against thestandards. NCQA reviews a report with at least five days of data showing appointmentwait times, compared with defined standards.Factor 5: NCQA reviews a documented process for monitoring scheduled visits. NCQAreviews a report from a recent 30-calendar-day period showing number of scheduledvisits; number of patients actually seen, number of no-shows; and a calculated rateusing scheduled visits as the denominator and patients seen as the numerator or bytaking the number of patients who did not keep their pre-scheduled appointments duringa specific period of time (i.e. a session or a day) divided by the number of patients whoNovember 16, 2015NCQA Patient-Centered Medical Home 2014

32PCMH 1: Patient-Centered Accesswere pre-scheduled to come to the center for appointments during the same period oftime.Factor 6: NCQA reviews a documented process for selecting, analyzing and updatingits approach to creating access to appointments that considers appointment supply andpatient demand by: Including criteria for selecting areas of focus. Describing how the practice monitors areas of focus. Describing how the practice sets targets for improvement. Specifying how often criteria for creating greater access to appointments arerevisited. Outlining when targets may be adjusted.NCQA reviews a report showing the practice has evaluated data on access, selected atleast one opportunity to improve access and took at least one action to create greateraccess.NCQA Patient-Centered Medical Home 2014November 16, 2015

PCMH 1: Patient-Centered AccessElement B: 24/7 Access to Clinical Advice3.50 pointsThe practice has a written process and defined standards for providingaccess to clinical advice and continuity of medical record information atall times, and regularly assesses its performance on:YesNo1. Providing continuity of medical record information for care and advicewhen office is closed. 2. Providing timely clinical advice by telephone. (CRITICAL FACTOR) 3. Providing timely clinical advice using a secure, interactive electronicsystem. 4. Documenting clinical advice in patient records. 100%The practicemeets all 4factorsScoringExplanation75%The practicemeets 3factors(includingfactor 2)3350%The practicemeets 2factors(includingfactor 2)25%The practicemeets 1 factor(or does notmeet factor 2)NA 0%The practicemeets 0factorsFactor 1: The practice makes patient clinical information available to on-call staff,external facilities, and other clinicians outside the practice when the office is closed.Access to the medical record may include direct access to the paper or electronicrecord or by arranging a telephone consultation with a clinician who has access to themedical record.If care is provided by a facility that is not affiliated with the practice or does not haveaccess to patient records, the practice provides patients with an electronic or printedcopy of a clinical summary of their medical record. One option may be for patients toconvey needed information via individualized care plans or portable personal healthrecords, or through patient access to an electronic health record (EHR).Telephone consultation with the primary clinician or with a clinician who has access tothe patient’s medical record meets the requirement. The practice’s process forensuring access includes a method for ensuring access by practice clinicians whenthe office is closed.Factors 2, 3: Factor 2 is a critical factor and must be met for practices to scorehigher than 25% on this element.Patients can seek and receive interactive (i.e., questions are answered by a person,rather than by a recorded message) clinical advice by telephone (factor 2) or secureelectronic communication (factor 3) (e.g., electronic message, Web site) when theoffice is open and closed.Clinicians return calls and respond to secure electronic messages in the time framedefined by the practice to meet the clinical needs of the patient population.The practice may have different standards for when the office is open and when theoffice is closed and may have different standards for electronic versus telephoniccommunications.Factor 3: If patients can submit requests for clinical advice after office hours, thepractice has an obligation to provide a timely response. The practice defines thetypes of inquiries that should be made electronically, and its response time frame(e.g., a secure message sent after hours receives an automatic reply informing thesender that urgent situations require a phone call and that “routine” electronicmessage