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

Page | 14

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

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

Page | 14

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

October 2011
Oregon Health Authority

Page | 14

October 2011
Oregon Health Authority

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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.
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, 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,
finance, etc.
What patient population do you serve? (choose one)
Adult population only

Pediatric population only

Adult and pediatric populations
Do you provide obstetrics care?
Do you provide complementary and alternative medicine (CAM) such as
naturopathic care, acupuncture, massage, etc.?
How many providers and other clinical staff provide direct patient care at
this practice site?
Number of clinicians (MD, DO, PA, NP, ND)
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)

1.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.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.g., clinic staff on call,
contracted third party):
Is the person giving clinical advice a member of the patients own care team? Choose
one
After hours or on weekends, 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, approach)
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?

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?
1.F) Prescription Refills
Describe how your practice tracks time to completion (may include average time,
general description, or similar information)
What is your practice's current average time to completion for prescription refills?
2.A) Performance & Clinical Quality
No Optional Questions
2.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, caregivers, 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, caregiver, and family advisors into the clinic and
do they function in peer support, or in training roles?
Describe how these groups are integrated into your clinic and function in peer support,
or in training roles:
2.D) Quality Improvement
Does your practice use performance data to improve clinical quality, 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, 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.
Has your practice documented a clinic-wide improvement strategy with performance
goals derived from patient, family, caregiver and other team feedback, publicly
reported measures, 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?

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.E) Ambulatory Sensitive Utilization
Which utilization measure(s) is your practice tracking? (check all that apply)
Ambulatory Care Sensitive Conditions
Care Transition - 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, 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?

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:

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.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?
4.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.
4.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.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.
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, with results)
Images
Recent clinic notes

Are your providers able to transmit prescriptions electronically directly to pharmacies

via computer?
4.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.F) Planning for Continuity
Does your practice have a process for reassigning administrative requests, prescription
refills, and clinical questions when a provider is not available?
Describe this process:
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.
Numerator: Number of transitions of care, as below, where medication reconciliation
was performed.
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.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?

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?
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.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?
5.D) Test & Result Tracking
Describe the process for tracking tests (laboratory tests, x-rays etc.) 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, please describe the audit process:
5.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.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?
6.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, if applicable.
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, if applicable.
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.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?

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?
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.3 Numerator
6.B.3 Denominator
6.B.3 Percentage (must be more than 10%)
6.C) Experience of Care
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 Summary Score:
CAHPS Domain: Getting Timely Appointments, Care, and Information (% positive):
CAHPS Domain: How Well Doctors Communicate With Patients (% positive):
CAHPS Domain: Helpful, Courteous, 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, patients, staff)
6.D) Communication of Rights, Roles and Responsibilities
Describe your practice's process to provide patients these materials at the onset of the
care relationship.

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

Abdominal Aortic Aneurysm Screening: Men

USPSTF
Alcohol Misuse Counseling; USPSTF
Aspirin to prevent CVD: Men USPSTF

Blood Pressure Screening in Adults: USPSTF

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

Blood Pressure Screening in Children: USPSTF

Comprehensive Newborn Screening; Children
(USPSTF)
Depression Screening: Adolescents; USPSTF
Dyslipidemia Screening; Children (USPSTF)
Dental Caries Chemoprevention: Preschool
Children; USPSTF
Gonorrhea Prophylactic Medication: Newborns;
USPSTF
Hearing Loss Screening: Newborns; USPSTF
Iron Supplementation in Children: USPSTF
Obesity Screening and Counseling: Children;
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; 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; Women (HRSA)
STI Counseling (HRSA)
Well Woman Annual Visits (HRSA)