PCMH Standards & Guidelines 101: Care
Coordination and Care Transitions (CC)
fully solved to pass
CC 01 Lab and Imaging Test Management - correct answer ✔✔The practice systematically
manages lab and imaging tests by:
A. Tracking lab tests until results are available, flagging and following up on overdue results.
B. Tracking imaging tests until results are available, flagging and following up on overdue results.
C. Flagging abnormal lab results, bringing them to the attention of the clinician.
D. Flagging abnormal imaging results, bringing them to the attention of the clinician.
E. Notifying patients/families/caregivers of normal lab and imaging test results.
F. Notifying patients/families/caregivers of abnormal lab and imaging test results.
CC 01 Lab and Imaging Test Management (Guidance & Evidence) - correct answer ✔✔Guidance:
The practice demonstrates how it manages
patient tests and test results (report, log,
examples or electronic tracking system). If
frequent lab tests are ordered for a patient, the
practice provides the patient/family/caregiver (as
appropriate) with all initial results, clear
expectations for follow-up results and a plan for
handling abnormal findings.
Ineffective management of laboratory and imaging
test results can result in less than optimal care,
excess costs, and may compromise patient safety.
,Systematic monitoring helps ensure that needed
tests are performed and that results are acted on,
when necessary.
A, B. The practice tracks lab and imaging tests from the time they are ordered until results are
available, and flags test results that have not been made available. The flag may be an icon that
automatically appears in the electronic system or a manual tracking system with a timely
surveillance process. The practice follows up with the lab or diagnostic center (and the patient,
if necessary) to determine why results are overdue, and documents follow-up efforts until
reports are received.
C, D. Abnormal results of lab or imaging tests are flagged and brought to the attention of the
clinician, to ensure timely follow-up with the patient/family/caregiver.
E, F. The practice provides timely notification to patients about test results (normal and
abnormal). Filing results in the medical record for discussion during a scheduled office visit does
not meet the requirement.
Evidence
- Documented process
AND
- Evidence of implementation
CC 02 Newborn Screenings - correct answer ✔✔Follows up with the inpatient facility about
newborn hearing and blood-spot screening.
CC 02 Newborn Screenings (Guidance & Evidence) - correct answer ✔✔Guidance:
The practice follows up with the hospital or state
health department if it does not receive screening
, results.
Most states mandate that birthing facilities perform
a blood-spot test to screen for congenital
conditions (based on recommendations by the
American Academy of Pediatrics and the
American College of Medical Genetics) and a
hearing screening on all newborns. Early
detection and treatment of congenital disorders
can enhance health outcomes for newborns with
positive (abnormal) screening results.
Practices that do not see newborn patients are not
eligible for this elective criterion.
Evidence:
- Documented process
AND
- Evidence of implementation
CC 03 Appropriate Use for Labs and Imaging - correct answer ✔✔Uses clinical protocols to
determine when imaging and lab tests are necessary.
CC 03 Appropriate Use for Labs and Imaging (Guidance & Evidence) - correct answer
✔✔Guidance:
The practice establishes clinical protocols based
on evidence-based guidelines, to determine when
Coordination and Care Transitions (CC)
fully solved to pass
CC 01 Lab and Imaging Test Management - correct answer ✔✔The practice systematically
manages lab and imaging tests by:
A. Tracking lab tests until results are available, flagging and following up on overdue results.
B. Tracking imaging tests until results are available, flagging and following up on overdue results.
C. Flagging abnormal lab results, bringing them to the attention of the clinician.
D. Flagging abnormal imaging results, bringing them to the attention of the clinician.
E. Notifying patients/families/caregivers of normal lab and imaging test results.
F. Notifying patients/families/caregivers of abnormal lab and imaging test results.
CC 01 Lab and Imaging Test Management (Guidance & Evidence) - correct answer ✔✔Guidance:
The practice demonstrates how it manages
patient tests and test results (report, log,
examples or electronic tracking system). If
frequent lab tests are ordered for a patient, the
practice provides the patient/family/caregiver (as
appropriate) with all initial results, clear
expectations for follow-up results and a plan for
handling abnormal findings.
Ineffective management of laboratory and imaging
test results can result in less than optimal care,
excess costs, and may compromise patient safety.
,Systematic monitoring helps ensure that needed
tests are performed and that results are acted on,
when necessary.
A, B. The practice tracks lab and imaging tests from the time they are ordered until results are
available, and flags test results that have not been made available. The flag may be an icon that
automatically appears in the electronic system or a manual tracking system with a timely
surveillance process. The practice follows up with the lab or diagnostic center (and the patient,
if necessary) to determine why results are overdue, and documents follow-up efforts until
reports are received.
C, D. Abnormal results of lab or imaging tests are flagged and brought to the attention of the
clinician, to ensure timely follow-up with the patient/family/caregiver.
E, F. The practice provides timely notification to patients about test results (normal and
abnormal). Filing results in the medical record for discussion during a scheduled office visit does
not meet the requirement.
Evidence
- Documented process
AND
- Evidence of implementation
CC 02 Newborn Screenings - correct answer ✔✔Follows up with the inpatient facility about
newborn hearing and blood-spot screening.
CC 02 Newborn Screenings (Guidance & Evidence) - correct answer ✔✔Guidance:
The practice follows up with the hospital or state
health department if it does not receive screening
, results.
Most states mandate that birthing facilities perform
a blood-spot test to screen for congenital
conditions (based on recommendations by the
American Academy of Pediatrics and the
American College of Medical Genetics) and a
hearing screening on all newborns. Early
detection and treatment of congenital disorders
can enhance health outcomes for newborns with
positive (abnormal) screening results.
Practices that do not see newborn patients are not
eligible for this elective criterion.
Evidence:
- Documented process
AND
- Evidence of implementation
CC 03 Appropriate Use for Labs and Imaging - correct answer ✔✔Uses clinical protocols to
determine when imaging and lab tests are necessary.
CC 03 Appropriate Use for Labs and Imaging (Guidance & Evidence) - correct answer
✔✔Guidance:
The practice establishes clinical protocols based
on evidence-based guidelines, to determine when
