PCMH Baseline Assessment
This survey will ask you about procedures and processes that exist at your practice today. There are no right or wrong answers, so just complete each section as honestly as you can. We will use this survey to provide you with an understanding of the work that you may need to undertake in order to achieve PCMH recognition with NCQA. Please allow at least 10 minutes to complete the survey and answer the questions to the best of your ability. We will respond to you via email in approximately 5-7 business days. Thank you!
Contact Information
Name of Person Completing Survey
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First Name
Last Name
Practice / Physician's Name
*
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Australia
Austria
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Belize
Benin
Bermuda
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Bolivia
Bosnia and Herzegovina
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Burkina Faso
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Chile
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Mali
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Martinique
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Montenegro
Montserrat
Morocco
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Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
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Turkish Republic of Northern Cyprus
Northern Mariana
Norway
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Pakistan
Palau
Palestine
Panama
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Paraguay
Peru
Philippines
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Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
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Samoa
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Solomon Islands
Somalia
Somaliland
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Spain
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eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
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Turkey
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Western Sahara
Yemen
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Zimbabwe
Other
Country
Phone Number
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-
Area Code
Phone Number
E-mail
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Primary Specialty
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A. General Questions
A.1. Regarding electronic medical records (EMR):
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Yes
No
We currently use an electronic medical record (EMR)
We are about to start using an EMR
We have no plans to use an EMR
A.2. If you are about to implement an EMR, please enter a date (month, year) for implementation:
A.3. What EMR vendor do you / will you be using?
A.4. If using an EMR, have you achieved Meaningful Use?
Yes
No
Not sure
A.5. If using an EMR, does it contain any special features supporting PCMH?
Yes
No
Not sure
A.6. Regarding the Patient Centered Medical Home (PCMH) Process:
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Yes
No
I/We know little about the NCQA PCMH process
I/We have started the process of looking into the NCQA PCMH Program
I/We have completed training with NCQA
I/We have begun compiling data necessary for the NCQA program
A.7. When are you considering starting the Program? (please enter month, year)
A.8. How many locations do you have / would like recognized as medical home(s)?
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B. Access & Continuity
B.1. Regarding Access During Office Hours - please check off the most appropriate answer for each question
We do this
We do this AND have a written process for it
We can do this but don't right now
We do not / cannot do this
I do not know if we do / can do this
We provide same-day appointments
We provide timely clinical advice by telephone during office hours
We provide timely clinical advice by secure electronic messages during office hours
We document clinical advice in the medical record
B.2. Regarding After-Hours Access - please check off the most appropriate answer for each question
We do this
We do this AND have a written process for it
We can do this but don't right now
We do not / cannot do this
I do not know if we do / can do this
We provide access to routine and urgent-care appointments outside regular business hours
We provide continuity of medical record information for care and advice when the office is not open
We provide timely clinical advice by telephone when the office is not open
We provide timely clinical advice using a secure, interactive electronic system when the office is not open
We document after-hours clinical advice in patient records
B.3. Regarding Electronic Access - Practice can demonstrate that is does the following:
We do this
We can do this but don't right now
We cannot do this
I do not know if we do / can do this
We provide information to patients who request an electronic copy of their health information within 3 business days
At least 10 percent of patients have electronic access to their current health information within 4 business days
Clinical summaries are provided to patients for more than 50 percent of office visits within 3 business days
We allow two-way communication between patients/families and the practice [through a website, patient portal or secure email system]
Patients can request appointments or prescription refills electronically
Patients can request referrals or test results electronically
B.4. Regarding Continuity - please check off the most appropriate answer for each question
We do this
We do this AND record this in the patient record
We can do this but don't right now
We cannot record this in our system
I do not know if we do / can do this
We have patients/families select a personal clinician
We document the patient’s/family’s choice of clinician
We monitoring the percentage of patient visits with a selected clinician or team
B.5. Regarding Culturally & Linguistically Approriate Services (CLAS) - The practice engages in activities to understand and meet the cultural and linguistic needs of its patients/families by: (please check off the most appropriate answer for each question)
We do this
We do this AND have a written process for it
We can do this but don't right now
We don't do this
I do not know if we do / can do this
Assessing the racial and ethnic diversity of its population (through 3rd party data, polling patients in the practice, etc)
Assessing the language needs of its population (collecting data on patients language preferences and recording it in the patient chart)
Providing interpretation or bilingual services to meet the language needs of its population (through a staff member, 3rd party company etc)
Providing printed materials in the languages of its population
B.6. Regarding the Practice Team - The practice uses a team to provide a range of patient care services by: (please check off the most appropriate answer for each question)
We do this
We do this AND have written documentation on it
We don't do this
I do not know if we do / can do this
We have defined roles for clinical and nonclinical team members (e.g. job descriptions)
We have regular team meetings or a have a structured communication process
We use standing orders for services
We train and assign care teams to coordinate care for individual patients (such as how to coach patients)
We train and assign care teams to support patients and families in self-management, self-efficacy and behavior change
We train and assign care teams for patient population management (e.g., patients with specific clinical conditions)
We train and designate care team members in communication skills
We involve care team staff in the practice’s performance evaluation and quality improvement activities (e.g. meetings)
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C. Identifying and Managing Patient Populations - The practice systematically records patient information and uses it for population management to support patient care.
C.1. Regarding Patient Information - The practice uses an electronic system that records the following as structured (searchable) data for more than 50 percent of its patients: (please check off the most appropriate answer for each question)
Yes, we record this
We can record it but do not
We cannot record this
I don't know if we can do this
Date of birth
Gender
Race
Ethnicity
Preferred Language
Telephone numbers
Date of previous clinical visits
Legal guardian / health care proxy
Primary caregiver
Presence of advanced directives
Health insurance information
C.2. Regarding Clinical Data - The practice uses an electronic system to record the following as structured (searchable) data: (please check off the most appropriate answer for each question)
Yes, we do this
No, we don't do this
We can do this but don't
We cannot record this
N/A
An up-to-date problem list with current and active diagnoses
Allergies, including medication allergies and adverse reactions,
Blood pressure for patients 2 years and older
Height for patients 2 years and older
Weight for patients 2 years and older
System calculates and displays BMI (NA for pediatrics)
System plots and displays growth charts and BMI percentile (2–20 years) (NA for adult practices)
Status of tobacco use for patients 13 years and older
List of prescription medications
C.3. Comprehensive Health Assessment - To understand the health risks and information needs of patients/families, the practice conducts and documents a comprehensive health assessment that includes: (please check off the most appropriate answer for each question)
Yes, we do this
No, we don't do this
We can do this but don't
We cannot record this
N/A
Documentation of age- and gender-appropriate immunizations and screenings
Family/social/cultural characteristics
Communication needs
Medical history of patient and family
Advance care planning (NA for pediatric practices)
Behaviors affecting health
Patient and family mental health/substance abuse
Developmental screening using a standardized tool (NA for adult-only practices)
Depression screening for adults and adolescents using a standardized tool
C.4. Regarding Using Data for Population Management - The practice uses patient information, clinical data and evidence-based guidelines to generate lists of patients and to proactively remind patients/ families and clinicians of services needed for: (please check off the most appropriate answer for each question)
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
We use evidenced-based guidelines for managing certain conditions
We can run reports to recall patients that are overdue for visits
We can run reports to recall patients that are overdue for tests
We remind patients to come in for overdue visits / tests
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D. Planning and Managing Care - The practice systematically identifies individual patients and plans, manages and coordinates their care, based on their condition and needs and on evidence-based guidelines.
D.1. Regarding Care Management - The care team can or does perfom the following for at least 75 percent of the patients identified for select conditions
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Conduct pre-visit preparations
Collaborate with the patient/family to develop an individual care plan
Give patient/family a written plan of care
Assess and address barriers when the patient has not met treatment goals
Give patient/family a clinical summary at each relevant visit
Identify patients/families who might benefit from additional care management support
Follow up with patients/families who have not kept important appointments
D.2. Regarding Medication Management - The practice does or can manage medications in the following ways
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Review and reconcile medications with patients/families for care transitions
Provide information about new prescriptions to patients/families
Assess patient/family understanding of medications
Assess patient response to medications and barriers to adherence
Document over-the-counter medications, herbal therapies and supplements
D.3. Regarding Electronic Prescribing - The practice uses an electronic prescribing system and with the following capabilities
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Generates and transmits eligible prescriptions to pharmacies
Enters electronic medication orders into the medical record
Performs patient-specific checks for drug-drug and drug-allergy interactions
Alerts prescribers to generic alternatives
Alerts prescribers to formulary status
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E. Providing Self-Care Support and Community Resources - The practice acts to improve patients' ability to manage their health by providing a self- care plan, tools, educational resources and ongoing support.
E.1. Regarding Supporting Patient's Self-Care - The practice conducts activities to support patients/families in self-management in the following ways:
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Provides educational resources or refers patients/families to educational resources to assist in self-management
Uses an EMR to identify patient-specific education resources and provide them to patients
Develops and documents self-management plans and goals in collaboration with patients/families
Documents self-management abilities of patients/families
Provides self-management tools to record self-care results (e.g. food diary)
Counsels patients/families to adopt healthy behaviors
E.2. Regarding Patient Referrals to Community Resources -
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Maintains a current resource list on five topics or key community service areas of importance to the patient population
Tracks referrals provided to patients/families
Arranges or provides treatment for mental health and substance abuse disorders
Offers opportunities for health education programs (such as group classes and peer support.)
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F. Tracking and Coordinating Care - The practice systematically tracks tests and coordinates care across specialty care, facility-based care and community organizations.
F.1. Regarding Test Tracking and Follow-Up - The practice has a documented process for and demonstrates that it can:
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Track lab tests until results are available, flagging and following up on overdue results
Track imaging tests until results are available, flagging and following up on overdue results
Flag abnormal lab results, bringing them to the attention of the clinician
Flag abnormal imaging results, bringing them to the attention of the clinician
Notify patients/families of normal and abnormal lab and imaging test results
Follow up with inpatient facilities on newborn hearing and blood-spot screening (NA for adults)
Electronically communicates with labs to order tests and retrieve results
Electronically communicates with facilities to order and retrieve imaging results
Electronically incorporate clinical lab test results into structured fields in medical records
Electronically incorporates imaging test results into medical records
F.2. Regarding Referral Tracking and Follow-Up - The practice coordinates referrals by:
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Giving the consultant or specialist the clinical reason for the referral and pertinent clinical information
Tracking the status of referrals, including required timing for receiving a specialist’s report
Following up to obtain a specialist’s report
Establishing and documenting agreements with specialists in the medical record if co-management is needed
Asking patients/families about self-referrals and requesting reports from clinicians
Demonstrating the capability for electronic exchange of key clinical information between clinicians
Providing an electronic summary of the care record to another provider with referrals
F.3. Regarding Coordination With Facilities and Managing Care Transitions - On its own or in conjunction with an external organization, the practice:
Yes, we do this
No, we don't / can't do this
We can but do not do this
I don't know if we can do this
Has a process for identifying patients with a hospital admission and patients with an emergency department visit
Has a process for sharing clinical information with admitting hospitals and emergency departments
Has a process for consistently obtaining patient discharge summaries from the hospital and other facilities
Has a process for contacting patients/families for appropriate follow-up care within an appropriate period
Has a process for exchanging patient information with the hospital during a patient’s hospitalization
Collaborates with the patient/family to develop a written care plan for patients transitioning from pediatric care to adult care
Demonstrates the capability for electronic exchange of key clinical information with facilities
Provides an electronic summary-of-care record to another care facility
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G. Measuring and Improving Performance - The practice uses performance data to identify opportunities for improvement and acts to improve clinical quality, efficiency and patient experience.
G.1. Regarding Measuring Performance
Yes, we do this
No, we don't / can't do this
I don't know if we can do this
The practice has ability to review its performance on a range of measures to help opportunities for improvement. (Data from EMR or from Payer)
G.2. Regarding Measuring Patient / Family Experience
Yes
No
Don't Know
The practice conducts a survey (using any instrument) to evaluate patient/family experiences
The practice uses the CAHPS Patient-Centered Medical Home (PCMH) survey tool
The practice obtains feedback on the experiences of vulnerable patient groups (disabled, infirm)
The practice obtains feedback from patients/families through qualitative means (focus groups, interviews etc)
G.3. Regarding Implementing Continuous Quality Improvement - the practice has a process to:
Yes
No
Don't Know
Set goals and act to improve performance
Set goals and address at least one identified disparity in care or service for vulnerable populations
Involve patients/families in quality improvement teams or on the practice’s advisory council
G.4. Regarding Demonstrating Continuous Quality Improvement - The practice demonstrates ongoing monitoring of the effectiveness of its improvement process by:
Yes
No
Don't Know
Tracking results over time
Assessing the effect of its actions
Achieving improved performance
G.5. Regarding Reporting Performance -
I/We do
I/We can but don't
I/We cannot
Don't Know
The practice shares performance data within the practice, results by individual clinician
The practice shares performance data across the practice
The practice shares performance data outside the practice to patients or publicly
G.6. Regarding Reporting Data Externally - The practice electronically reports:
I/We do
I/We can but don't
I/We cannot
Don't Know
Ambulatory clinical quality measures to CMS or states
Ambulatory clinical quality measures to other external entities
Data to immunization registries or systems
Syndromic surveillance data to public health agencies
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