Please refer to the 2014 TA Guide and enter the score that corresponds with the answer(s) selected for each
standard. Practices are required to meet all 10 must-pass measures and report quantitative data for select
standards. All services, processes, and procedures that a practice attests to on the PCPCH application must be in
place at the time the application is submitted.
Meet Quantitative
Must-Pass Data
Enter
2014 PCPCH Standard (enter a Required
Score
value of 1)
Number of other clinical staff that provide direct patient care (e.g. RN, MA, social
worker, psychologist, registered dietician, etc.)
Approximately how many unique patients does this practice site care for on an
annual basis?
Optional Questions
1.A) In-Person Access
Does your practice use a patient experience survey? If yes, 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)
Please provide a text description of the hours available and how they are managed:
How many requests for electronic health records were received in the last year?
How many of these requests for electronic health records were fulfilled?
Does your practice provide patients/families with access to an interactive patient
portal website where they have access to their electronic health information, can
schedule appointments, etc?
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.C) Mental Health, Substance Abuse & Developmental Services (check all that apply)
Describe your process for conducting universal screening for mental health, substance
use, 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, or developmental providers?
Does your practice have co-located behavioral or specialty mental health, substance
abuse, 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, are same day
services available with behavioral health providers?
3.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,
medication, follow-up appointments, referral):
3.E) Preventive Services Reminders
Does your practice uses patient information, clinical data, 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?
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, such as a pop-up within
an EHR or an appropriate reminder attached to the chart?
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.
Describe the providers/entities you exchange information with and the method used:
Process for sharing of patient medical records at the time of hospital admission
Does your practice track the percentage of patients whose medication is reconciled?
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?
5.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.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, person-centered care plan?
Do you have processes to support patients who are high utilizers of medical services?
Does your practice use care management teams (i.e. 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.e. sit together) in the clinic?
Has your clinic audited its internal tracking system to determine the timeliness of
receipt of test results and notification of clinicians and patients?
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.g.
appointment completion status, appointment date, urgency of the referral)?
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, SNF or long term care facility?)
Describe your process for managing and coordinating the care your patients receive in
hospitals, skilled nursing or long-term care facilities:
Does your practice track referrals and cooperate with community service providers
outside the practice, such as dental, educational, social service, foster care, public
health, 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.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, living wills, or POLST forms), as
well as ensuring they are in the medical record and submitted to available registries?
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.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 patient-
specific educational resources during the last 12 months?
6.B.2 Numerator
6.B.2 Denominator
6.B.2 Percentage (must be more than 10%)
Do your clinic's providers meet either of the following Meaningful Use measures?