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Self-Assessment Scoring Page

Please refer to the 2014 TA Guide and enter the score that corresponds with the answer(s) selected for e
standard. Practices are required to meet all 10 must-pass measures and report quantitative data for sele
standards. All services, processes, and procedures that a practice attests to on the PCPCH application m
place at the time the application is submitted.

2014 PCPCH Standard

Meet
Must-Pass
(enter a
value of 1)

1.A) In-Person Access
1.B) After Hours Access
1.C) Telephone & Electronic Access
1.D) Same Day Access
1.E) Electronic Access
1.F) Prescription Refills
2.A) Performance & Clinical Quality
2.B) Public Reporting
2.C) Patient and Family Involvement in Quality Improvement
2.D) Quality Improvement
2.E) Ambulatory Sensitive Utilization
3.A) Preventive Services
3.B) Medical Services
3.C) Mental Health, Substance Abuse & Developmental Services
(check all that apply)
3.D) Comprehensive Health Assessment & Intervention
3.E) Preventive Services Reminders
4.A) Personal Clinician Assigned
4.B) Personal Clinician Continuity
4.C) Organization of Clinical Information
4.D) Clinical Information Exchange
4.E) Specialized Care Setting Transitions
4.F) Planning for Continuity
4.G) Medication Reconciliation
5.A) Population Data Management (check all that apply)
5.B) Electronic Health Record
5.C) Complex Care Coordination (check all that apply)
October 2011
Oregon Health Authority

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5.D) Test & Result Tracking
5.E) Referral & Specialty Care Coordination (check all that apply)
5.F) End of Life Planning
6.A) Language/Cultural Inperpretation
6.B) Education & Self-Management Support
6.C) Experience of Care
6.D) Communication of Rights, Roles and Responsibilities
TOTAL

0

PCPCH Tier 1: 30-60 points and all 10 Must-Pass Measures
PCPCH Tier 2: 65-125 points and all 10 Must-Pass Measures
PCPCH Tier 3: 130 points or more and all 10 Must-Pass Measures

October 2011
Oregon Health Authority

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nswer(s) selected for each antitative data for select e PCPCH application must be in Enter Score Click here to view the 2014 TA Guide Quantitative Data Required ü October 2011 Oregon Health Authority Page | 14 .

0 October 2011 Oregon Health Authority Page | 14 .

Family Medicine Clinic Internal Medicine Clinic Pediatric and/or Adolescent Clinic Women's Health Clinic Residency Training Clinic Community Health Center Solo Private Practice School Based Health Center Federally Qualified Health Center Rural Health Center (designated) Military or Veteran's Administration Clinic Behavioral/Mental Health Clinic with integrated primary care Native American or Indian Health Clinic Naturopathic Clinic Other (please specify) Please describe your organizational structure in terms of practice ownership and independence: (choose one) Independent.Additional Required Questions: Organization Information Organization Name Organization Tax ID Organization NPI Number Organization Oregon Medicaid ID Organization Contact Person Organization Contact Email Organization Contact Phone Number Organization Address Practice Site Information Practice Site Name Practice Site Tax ID Practice Site NPI Number Practice Site Oregon Medicaid ID Practice Site Contact Person Practice Site Contact Email Practice Site Contact Phone Number Practice Site Address Which describes this practice site? Please select all that apply. etc. unaffiliated with any other practice Independent governance but part of an alliance for shared group purchasing/other economies of scale (such as an IPA) Owned by a larger system that governs our practice and determines our operations. What patient population do you serve? (choose one) Adult population only . finance.

massage. psychologist. etc. PA. ND) Number of other clinical staff that provide direct patient care (e.) Approximately how many unique patients does this practice site care for on an annual basis? . RN.? How many providers and other clinical staff provide direct patient care at this practice site? Number of clinicians (MD. registered dietician. acupuncture. MA. DO. NP. etc.Pediatric population only Adult and pediatric populations Do you provide obstetrics care? Do you provide complementary and alternative medicine (CAM) such as naturopathic care. social worker.g.

clinic staff on call.Optional Questions 1. does your practice provide urgent phone response from a clinical provider within a specified time? 1..D) Same Day Access Does your practice provide same day appointments that are not overbooks of existing appointments? Describe the method by which your practice provides same day appointments (include number per day.g.B) After Hours Access How many hours each week do you have both urgent and routine appointments available at this practice site outside of 8am -5pm Monday through Friday? Please provide a text description of the hours available and how they are managed: 1.E) Electronic Access Does your practice provide patients with an electronic copy of their health information upon request (your approach must satisfy Meaningful Stage 1 or Stage 2 requirements) Do the providers meet any of the following Meaningful Use measures? How many requests for electronic health records were received in the last year? How many of these requests for electronic health records were fulfilled? . approach) 1. contracted third party): Is the person giving clinical advice a member of the patients own care team? Choose one After hours or on weekends. what is the survey name & version: Date survey administered: Number of surveys sent: Number of completed surveys received: CAHPS Access to care score: CAHPS Percentile: CAHPS Summary Score: Do you track any of these additional access measures? (check all appropriate) 1.A) In-Person Access Does your practice use a patient experience survey? If yes.C) Telephone & Electronic Access Are telephone encounters documented in patients' records within 24 hours of the call? Does your clinic provide 24/7 access to clinical advice by telephone? Describe the method by which you provide clinical advice (e.

efficiency and patient experience? Describe how the data is used: Does your practice have multi-disciplinary improvement teams that met at least 8-12 times during the last 12 months to review timely. actionable. general description.Does your practice provide patients/families with access to an interactive patient portal website where they have access to their electronic health information. and areas for clinical and operational improvement identified by the practice? Does the strategy include: Are you currently participating in or have you recently participated in any formal quality improvement collaboratives? .F) Prescription Refills Describe how your practice tracks time to completion (may include average time. or similar information) What is your practice's current average time to completion for prescription refills? 2. etc? 1. caregiver.B) Public Reporting Does your practice participate in any public reporting programs for quality/performance? Which public reporting program(s) does your practice participate in? Does your practice have the publically reported data with providers and staff at the clinic? Describe how your practice shares this data within your clinic for improvement purposes: 2.C) Patient and Family Involvement in Quality Improvement Did your practice involve patients.A) Performance & Clinical Quality No Optional Questions 2. or in training roles? Describe how these groups are integrated into your clinic and function in peer support. Has your practice documented a clinic-wide improvement strategy with performance goals derived from patient. caregiver and other team feedback. team-level data related to your chosen improvement project? Describe the composition of your multi-disciplinary quality improvement teams and how they are utilized at your practice.D) Quality Improvement Does your practice use performance data to improve clinical quality. and families on at least one quality or safety initiative during the last 12 months? Which quality or safety initiative(s) are these groups involved in? Has your practice established a formal way for integrating these groups into improvement activities? Please describe this mechanism: Does your practice integrate patient. and family advisors into the clinic and do they function in peer support. can schedule appointments. or in training roles: 2. caregivers. family. publicly reported measures.

and enacting evidence-based strategies to promote appropriate utilization? Please describe how your practice uses the utilization data to set goals and implement evidence-based strategies to promote appropriate utilization: Denominator (eligible patients) for this measure: Numerator (number of events) for this measure: Does your practice meet the utilization measure benchmark or has achieved at least a 5% improvement over 6 months or a 10% improvement over 12 months? 3.A) Preventive Services Does your practice use the best available evidence to offer or coordinate recommended age and gender appropriate preventive services? Which evidence-based recommendations does your practice use to base your preventive service offerings? Does your practice have a documented improvement strategy in effect to address gaps in preventive services offerings for your patient population? Please describe this improvement strategy: Which USPSTF/Bright Future Standards do you offer/coordinate? .Transition Record Transmitted to Health Care Professional Follow-up After Hospitalization for Mental Illness All-Cause Readmission Rate Does your practice set goals and work to optimize utilization through: monitoring selected measures on a regular basis.E) Ambulatory Sensitive Utilization Which utilization measure(s) is your practice tracking? (check all that apply) Ambulatory Care Sensitive Conditions Care Transition .a quality improvement methodology? Does your practice use a structured method for practice improvement in your organization? multiple improvement related projects? Are providers given feedback regarding their performance on clinical quality measures? feedback loops for spread of best practices? Individual/team performance data are shared with: [check all appropriate] The specific provider only All providers can see performance data All staff can see performance data Patients can see performance data How do you measure and report staff satisfaction? [check all appropriate] We do not do a staff satisfaction survey We do a staff satisfaction survey and share results with managers We do a staff satisfaction survey and share results with staff We do a staff satisfaction survey and share results with key stakeholders 2.

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3.B) Medical Services Does your practice routinely provide services under each of the categories? Acute Care: Office Based Procedures: Patient Self-Management: Management of Chronic Diseases: .

referral): 3. substance abuse. are same day services available with behavioral health providers? 3. and evidence-based guidelines to generate lists of patients who need reminders and proactively remind patients/families/caregivers and clinicians of needed services? Which patients are sent reminders and for what preventive services? Does your practice track the number of unique patients who were sent appropriate reminders? Do the providers meet any of the following Meaningful Use measures? Meaningful Use Stage 1 Menu Set Measure 4 Meaningful Use Stage 2 Core Measure 12 How many patients needed reminders over the last 30 days? .E) Preventive Services Reminders Does your practice uses patient information.D) Comprehensive Health Assessment & Intervention List one health risk or developmental promotion behavior you assess and intervene on: List a second health risk or developmental promotion behavior you assess and intervene on: List a third health risk or developmental promotion behavior you assess and intervene on: Describe the appropriate intervention when a health risk is identified (education. or developmental providers? Does your practice have co-located behavioral or specialty mental health.Office Based diagnostics tests: Management of transition of Care: Patient Education: Does your practice have staff who: [check all appropriate] Routinely remind patients about appointments and collect information prior to appointments? Meet with and/or call patients for basic health promotion? Meet with and/or call patients for to help educate them about managing their chronic illness? 3. or developmental conditions and what happens when patients have a positive screen? Which screening tools does your practice use for children and adolescents? Which screening tools does your practice use for adult populations? Does your practice directly collaborate or co-manage patients with outside specialty mental health. Substance Abuse & Developmental Services (check all that apply) Describe your process for conducting universal screening for mental health.C) Mental Health. or developmental providers? Do primary care and behavioral health providers share a common care plan (a formal written document)? If a patient needs mental health services during a regular medical visit. substance abuse. medication. substance use. follow-up appointments. clinical data.

4. with results) Images Recent clinic notes .A) Personal Clinician Assigned Is your practice reporting continuity data based on individual clinician or care team assignment? Describe your practice's patient assignment process and how you ensure that patients are assigned a personal clinician or team of their choice.B) Personal Clinician Continuity Is your practice reporting continuity data based on visits with individual clinicians or the care team? Describe your practice's process for fostering continuity of care by ensuring patients are seen by the personal clinician or team of their choice? 4.C) Organization of Clinical Information Do you have a health record with the following elements that you update at each visit as needed? Problem List Medication List Allergies Basic demographic information Do you assess for and document your patient's preferred language? BMI/BMI percentile Growth chart (select "N/A" if pediatric patients aged 0-18 are not seen) Immunization record 4.How many reminders were sent out over the last 30 days? Does your practice use guideline-based reminders for services patients should receive that providers can view at the time they are seeing patients.D) Clinical Information Exchange Does your practice share data electronically in real time with other providers and entities? Please note that secure faxing does not meet the intent of this standard. such as a pop-up within an EHR or an appropriate reminder attached to the chart? 4. Describe the providers/entities you exchange information with and the method used: Which types of information do you exchange in real time? With other providers With hospitals With pharmacies With skilled nursing facilities (or similar settings) Which types of information do you exchange in real time? Problem lists (as diagnoses or descriptions) Medication lists Allergies Lab results (as codes.

E) Specialized Care Setting Transitions Which hospitals or hospitalist groups most frequently care for your patients when they are hospitalized? Do you have a written document that serves as an agreement between your practice and these hospitals so that you are notified when your patients are admitted and discharged? Does the agreement also contain the following? Process for requesting hospital admission Process and performance expectations for communication at the time of hospital admission Process for sharing of patient medical records at the time of hospital admission Process and performance expectations for communication at the time of hospital discharge Process and performance expectations for scheduling after-hospital follow up appointments Are you notified when one of your patients is admitted or discharged from you usual hospital providers? Do you have a standard process to follow-up with patients after discharge? 4.G) Medication Reconciliation Does your practice track the percentage of patients whose medication is reconciled? Denominator: Number of transitions of care in the previous 12 months in which your practice was the receiving party of the transition.A) Population Data Management (check all that apply) Describe your process for using data to proactively manage the care needs of a subpopulation of your patients: Do you generate regular reports about patient data at the team/panel level? If yes to #1: Are the reports shared with: [check all appropriate] The specific provider teams whose patients are listed All providers so all can see all data If yes to #1: Are the reports shared with patients? . Does your practice's providers meet either of the following Meaningful Use measures? Meaningful Use Stage 1 Menu Set Measure 7 Meaningful Use Stage 2 Core Measure 14 5. Numerator: Number of transitions of care. prescription refills.F) Planning for Continuity Does your practice have a process for reassigning administrative requests.Are your providers able to transmit prescriptions electronically directly to pharmacies via computer? 4. and clinical questions when a provider is not available? Describe this process: 4. as below. where medication reconciliation was performed.

D) Test & Result Tracking Describe the process for tracking tests (laboratory tests. urgency of the referral)? .e. please describe the audit process: 5.C) Complex Care Coordination (check all that apply) Describe your clinic's process for identifying and communicating the person at the practice responsible for coordinating patient care: Describe how your practice defines 'complex needs'. How do you identify patients that meet this criteria? How many patients are high risk (having complex needs) in your clinic? Describe your clinic's process for coordinating the care of high-risk patients having complex care needs: Does your practice work with patients and families with complex medical of social concerns to develop anindividualized written.B) Electronic Health Record Please enter the Name of your Meaningful Use-certified EHR: EHR version: Have all of the providers at your clinic attested for Stage 1 or Stage 2 of Meaningful Use? 5.e. appointment completion status.) ordered in the practice: Does the log or tracking system used clearly identify whether test results have been received? Does the log or tracking system used clearly identify whether the patient and ordering clinician have been informed of test results? Has your clinic audited its internal tracking system to determine the timeliness of receipt of test results and notification of clinicians and patients? If yes. person-centered care plan? Does the care plan contain at least the following elements? patient-identified self management goals? goals of preventive and chronic illness care? action plan for exacerbations of chronic illness? Do you have processes to support patients who are high utilizers of medical services? Does your practice use care management teams (i.5. a group of providers and other staff who meet with each other regularly to discuss the care of a defined group of patients and who share responsibility for their care)? Are providers and other care team members co-located (i. appointment date.g. x-rays etc.E) Referral & Specialty Care Coordination (check all that apply) Describe your process for tracking specialty referrals ordered in the practice: Do you have a log or tracking system that clearly identifies status of the referral (e. sit together) in the clinic? 5.

non-traditional health workers and pharmacy services? Describe your process for managing and coordinating the care your patients receive with community service providers outside the practice: 5. educational. SNF or long term care facility?) Describe your process for managing and coordinating the care your patients receive in hospitals. Do you have bilingual staff to communicate with patients or family members in their language of choice? Do you use a telephonic or an in-person interpreter to communicate with patients in their language of choice? What is your process for providing language translation/interpretation support in your practice? Describe the materials you've translated into other languages. or POLST forms). if applicable. skilled nursing or long-term care facilities: Does your practice track referrals and cooperate with community service providers outside the practice. if applicable.B) Education & Self-Management Support Describe the types of patient-specific educational resources your clinic uses and the process for providing them to patients when appropriate: Does your practice track the number of unique patients that were provided patientspecific educational resources during the last 12 months? . as well as ensuring they are in the medical record and submitted to available registries? 6.F) End of Life Planning Please describe how your practice offers or coordinates hospice and palliative care and counseling for patients and their families who need these services: Does your practice engage your patients in end-of-life planning conversations and complete documents (such as advanced directives. foster care.Do you have a log or tracking system that clearly identifies whether a consultation report has been received by the clinic and if results have been communicated to the patient? Does your practice actively coordinate care for your patients in specialized settings (such as a hospital. living wills.A) Language/Cultural Inperpretation How many patients speak a language other than English in your practice? Do you assess for and document your patient's preferred language? Does your practice translate written patient materials into languages spoken by more than 30 households or 5% of your patient population? Describe the materials you've translated into other languages. Does your practice offer staff the opportunity to participate in formal training programs (either internally or externally) to improve their skills in patient communication? Does your practice offer staff the opportunity to participate in formal training programs (either internally or externally) to improve their skills in cultural competence? 6. such as dental. social service. public health.

6. Courteous. patients.B.2 Denominator 6.3 Percentage (must be more than 10%) 6. staff) 6.B.B.3 Denominator 6.2 Numerator 6. what is the survey name & version: Date survey administered: Number of surveys sent: Number of completed surveys received: CAHPS Summary Score: CAHPS Domain: Getting Timely Appointments.B. Roles and Responsibilities Describe your practice's process to provide patients these materials at the onset of the care relationship.D) Communication of Rights. and Information (% positive): CAHPS Domain: How Well Doctors Communicate With Patients (% positive): CAHPS Domain: Helpful. .C) Experience of Care Does your practice use a patient experience survey? If yes. and Respectful Office Staff (% positive): CAHPS Domain: Follow-up on Test Results (% positive): CAHPS Domain: Patients Rating of the Doctor (% positive): CAHPS Domain: Willingness to Recommend (% positive): In what ways are your patient satisfaction data used? (check all appropriate) Patient experience data are routinely reviewed by managers and used to improve services Patient experience data are routinely reviewed by providers/all staff and used to improve services Data are reported to stakeholders (board. Care.B.3 Numerator 6.2 Percentage (must be more than 10%) Do your clinic's providers meet either of the following Meaningful Use measures? Meaningful Use Stage 1 Menu Set Measure 6 Meaningful Use Stage 2 Core Measure 13 Does your practice provide and track both educational AND self-management services for your patients? 6.B.

s Selection Options Third next available appointment Office visit cycle time Percentage of no-show appointments Stage 1 Meaningful Use core measure #12 Stage 1 Meaningful Use menu measure #5 Stage 2 Meaningful Use measure #7 .

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USPSTF Aspirin to prevent CVD: Men USPSTF .Abdominal Aortic Aneurysm Screening: Men USPSTF Alcohol Misuse Counseling.

USPSTF Do you offer USPSTF Services for pregnant women? Anemia Screening: Pregnant Women. USPSTF Rh Incompatibility Screening: 24-28 weeks gestation. Counseling: USPSTF Breast Cancer Preventive Medication: USPSTF Cervical Cancer Screening: USPSTF Chlamydial Infection Screening: non-pregnant women. USPSTF Healthy Diet Counseling: USPSTF HIV Screening: USPSTF Breast Cancer Screening: USPSTF Obesity Screening and Counseling: Adults USPSTF Osteoporosis Screening: Women. USPSTF Do you offer USPSTF Services for children? . USPSTF Tobacco Use Counseling and Interventions: NonPregnant Adults. USPSTF Rh Incompatibility Screening: First Pregnancy visit. USPSTF Diabetes Screening: USPSTF Dyslipidemia Screening. Women (USPSTF) STIs Counseling: USPSTF Syphilis screening: non-pregnant persons.Blood Pressure Screening in Adults: USPSTF BRCA Screening. USPSTF Tobacco Use Counseling. (USPSTF) Gonorrhea Screening: Women. USPSTF Syphillis Screening: Pregnant Women. USPSTF Screening and counseling for interpersonal and domestic violence. Adults. USPSTF Bacteriuria Screening: Pregnant Women USPSTF Breastfeeding Counseling: USPSTF Folic Acid Supplementation: USPSTF Hepatitis B Screening: Pregnant Women. Pregnant Women. USPSTF Colorectal Cancer Screening: USPSTF Depression Screening: Adults.

USPSTF Gonorrhea Prophylactic Medication: Newborns. USPSTF Hearing Loss Screening: Newborns. USPSTF Dyslipidemia Screening. Children (USPSTF) Dental Caries Chemoprevention: Preschool Children. Children (HRSA) Contraceptive Methods and counseling (HRSA) Gestational Diabetes Screening (HRSA) HIV Screening (HRSA) HPV Testing (HRSA) Routine Vaccination (ACIP) Screening and counseling for interpersonal and domestic violence. USPSTF Vision Screening (USPSTF) Do you offer Bright Futures for children? Age Appropriate anticipatory guidance (Bright Futures) Alcohol and Drug Use Assessment (Bright Futures) Autism Screening (Bright Futures) Developmental Screening (Bright Futures) Lead Screening (Bright Futures) Oral Health (Bright Futures) Tuberculin Test (Bright Futures) Vision Screening (Bright Futures) Do you offer HRSA or ACIP Services? Comprehensive Newborn Screening. USPSTF Iron Supplementation in Children: USPSTF Obesity Screening and Counseling: Children. Women (HRSA) STI Counseling (HRSA) Well Woman Annual Visits (HRSA) .Blood Pressure Screening in Children: USPSTF Comprehensive Newborn Screening. Children (USPSTF) Depression Screening: Adolescents.