Standard 2 Identify and Manage Populations NCQA Recognition for Patient-Centered Medical Home 2011 Standards © Qualidigm

Identify and Manage Populations Elements PCMH 2A:Patient Information PCMH 2B:Clinical Data PCMH 2C:Comprehensive Health Assessment PCMH 2D:Use of Data for Population Management – MUST PASS

2A Patient InformationScoring and Documentation Practice uses a searchable electronic system and records data >50% of the time for the following: 1.Date of birth* 2.Gender* 3.Race* 4.Ethnicity* 5.Preferred language* 6.Telephone number 7. address 8.Dates of previous clinical visits 9.Legal guardian/healthcare proxy 10.Primary caregiver 11.Advance directives (N/A for pediatrics) 12.Health insurance *Core Meaningful Use Requirement 3 Points Scoring  9-12 factors = 100%  7-8 factors = 75%  5-6 factors = 50%  3-4 factors = 25%  0-2 factors = 0% Documentation  Report showing percentage of patients who received electronic copy of health information, access to requested health information, and electronic clinical summaries

2B Clinical DataScoring and Documentation Practice uses a searchable electronic system to record the following data: 1.Up-to-date problem list of active diagnoses for >80% of patients 2.Allergies, including medications and reactions, for >80% of patients 3.Blood pressure with date of recording for >50% of patients 4.Height for >50% of patients 5.Weight for >50% of patients 6.BMI for >50% of patients 7.For pediatric patients, length/height, weight, head circumference ( 50% of patients 8.Tobacco use status for patients 13 years and older for >50% of patients 9.List of prescription medications with date of update for >80% of patients All factors are Core Meaningful Use requirements 4 Points Scoring  9 factors = 100%  7-8 factors = 75%  5-6 factors = 50%  3-4 factors = 25%  0-2 factors = 0% Documentation  Report showing percentage of all patients seen in the last 3 months for each data field

2C Comprehensive Health Assessment Scoring and Documentation Practice conducts and documents a health assessment: 1.Age and gender appropriate immunizations/screenings 2.Family/social/cultural characteristics 3.Communication needs 4.Medical history of patient and family 5.Advance care planning (N/A for pediatric practices) 6.Behaviors affecting health 7.Patient and family mental health/substance abuse 8.Developmental screening using standardized tool (N/A for adult only practices) 9.Depression screening for teens/adults using standardized tool 4 Points Scoring  8-9 factors = 100%  6-7 factors = 75%  4-5 factors = 50%  2-3 factor = 25%  0-1 factor = 0% Documentation  Report or a completed patient assessment (de-identified)

2D Use of Data for Population Management Scoring and Documentation Practice uses patient data and evidence-based guidelines to generate lists and to remind patients about needed services: 1. At least 3 different preventive care services* 2. At least 3 different chronic care services* 3. Patients not recently seen by the practice 4. Specific medications *Menu Meaningful Use Requirement MUST PASS 5 Points Scoring  4 factors = 100%  3 factors = 75%  2 factors = 50%  1 factor = 25%  0 factors = 0% Documentation  Lists or summary reports of patients who need services  Reports must contain at least 3 different immunizations/screenings and at least 3 different acute/chronic care services  Materials demonstrating patient notification