Draft Medicaid Primary Care Standards
June 9, 2008
General Standards (apply to all primary care clinicians in all settings)
- All Medicaid patients shall be offered the opportunity to select or change their own primary care clinician (PCC).
- Primary care physicians (MD/DO) must be Board Certified or Board Eligible in their area of specialty, or have completed an accredited residency program in Internal Medicine, Family Practice, Pediatrics, or Obstetrics/Gynecology, or meet the standards for residents training in those fields as described in Additional Standards for Article 28 Facilities with Training Programs in Internal Medicine, Pediatrics, and/or Family Practice".
- Primary care nurse practitioners must be certified in a primary care specialty.
- Physicians must either have admitting privileges at one or more hospitals or have an arrangement for hospital coverage (hospitalist is acceptable) provided there is a mechanism to share patient information for continuity and follow up care.
- Clinicians billing for primary care services shall provide health counseling, education and advice; conduct baseline and periodic health examinations with content consistent with EPSDT/CTHP requirements and professional guidelines including the US Preventive Services Task Force; diagnose and treat conditions not requiring services of another specialist; arrange inpatient care, consultations with specialists, laboratory and radiologic services when medically necessary; coordinate findings and recommendations of specialists and diagnostic results; interpret findings to the patient and patient's family as appropriate and allowable under confidentiality rules; maintain a current medical record for the patient.
- Practices must provide 24 hour/7 day week coverage (after hours and weekend/vacation number to call that leads to a person or message that can be returned within one half hour).
- Practices must: 1) identify to patients the name of the person who is their primary care clinician; 2) promote an ongoing relationship with an identified primary care clinician who will provide continuous and comprehensive care; 3) make use of a practice care team when necessary to assure continuity.
- Practices must monitor appointment availability and time slots to ensure timely access to routine or planned care as well as expedited or same day care for immediate health care needs; allow sufficient time for physical examinations and treatments; allow sufficient time for patient education.
- Practices must provide reminders/call backs to patients needing continued or follow-up services for primary and secondary prevention.
- Practices must provide self-management support (education, care plans, etc.), directly or through use of ancillary staff for individuals with chronic conditions including but not limited to diabetes and asthma.
- Practices must have the means to incorporate evidence based guidelines into practice for periodicity/prevention schedules, and guidelines for at least one chronic disease of high prevalence.
- Practices must provide assistance, or referral for assistance, to patients/families to obtain public insurance if uninsured.
- Clinicians must agree to participate in Medicaid utilization review programs and quality improvement initiatives (through health plan or through the Department of Health or its designated vendor(s)).
Additional Standards for Article 28 Facilities with Training Programs in Internal Medicine, Pediatrics, and/or Family Practice
- Full time ambulatory care sites must operate at least 40 hours/week including at least eight (8) hours during evenings or weekends.
- All Medicaid patients shall be assigned a primary care clinician (PCC) who shall be an attending physician, nurse practitioner, or resident physician (provided the requirements for supervision and care continuity are met). Programs will ensure that Medicaid patients are seen by their PCC to the maximum extent possible.
- Residents shall be assigned to a stable team consisting of at least one permanent attending physician (team lead and preceptor) and one or more permanent nurse practitioner(s), who provide continuity of care for a panel of patients. Members of the team will see patients when the assigned PCC is not available.
- Residents, as part of a team which includes the attending physician, may be designated as the PCC for Medicaid patients, and will follow patients over the course of their training period; these visits must be under the supervision of the team's attending physician / preceptor.
- Programs shall report annually a measure of continuity which calculates the percent of patient visits in which patients see their designated PCC.
- Residents must be available in an ambulatory care setting at least twenty (20) percent of the total training time with no less than ten (10) percent of training time in any training year in ambulatory care setting and no fewer than nine (9) months of a year in ambulatory care setting; residents are not away from ambulatory setting for periods longer than six consecutive weeks.
- Medicaid patients have the right to request and receive care by their attending/preceptor in addition to or instead of being seen by a resident.
- There shall be no less than one (1) full time supervising faculty attending for every four (4) residents working the clinic.
- There must be regular and formal mechanisms for sharing clinical information regarding patients among team members.
- Programs must have systems to facilitate the scheduling of regular appointments for ongoing care with the primary care attending team.
- Programs must have the capacity to track and monitor consultations/referrals and hospitalized patients.