Clinician: Group/Practice

The Medical Home System Survey (MHSS) assesses the degree to which an individual primary-care practice or provider has in place the structures and processes of an evidence-based Patient Centered Medical Home. The survey is composed of six composites. Each measure is used to assess a particular domain of the patient-centered medical home.

Composite 1: Patient-Centered Access
Composite 2: Team-Based Care
Composite 3: Population Health Management
Composite 4: Care Management and Support
Composite 5: Care Coordination and Care Transitions

Percentage of patient visits, regardless of age, seen with a new occurrence of melanoma who have a treatment plan documented in the chart that was communicated to the physician(s) providing continuing care within one month of diagnosis.

Percentage of patients, regardless of age, with a current diagnosis of melanoma or a history of melanoma whose information was entered, at least once within a 12 month reporting period, into a recall system that includes:
• A target date for the next complete physical skin exam , AND
• A process to follow up with patients who either did not make an appointment within the specified timeframe or who missed a scheduled appointment

This measure identifies adult patients with rheumatoid arthritis who were prescribed at least a 6-month supply of methotrexate during the measurement year and received a CBC test within 120 days (3 months + 1 month grace period) following the earliest observed methotrexate prescription claim

This measure identifies adult patients with rheumatoid arthritis who were prescribed at least a 6-month supply of methotrexate during the measurement year and received a serum creatinine test in the 120 days (3 months + 1 month grace period) after the earliest observed methotrexate prescription claim.

This measure identifies adult patients with rheumatoid arthritis who were prescribed at least a 6-month supply of methotrexate during the measurement year and received a liver function test (LFT) in the 120 days (3 months + 1 month grace period) following the earliest observed methotrexate prescription claim.

The percentage of patients aged 18 years and older diagnosed with myocardial infarction (MI) who are taking a beta blocker

Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both

This supplemental set of items was developed jointly by NCQA and the AHRQ-sponsored CAHPS Consortium and is intended for use with the CAHPS 4.0 Health Plan survey. Some items are intended for Commercial health plan members only and are not included here. This measure provides information on the experiences of Medicaid health plan members with the organization. Results summarize member experiences through composites and question summary rates.

This measure identifies patients with new-onset atrial fibrillation during the measurement year who have had a thyroid function test 6 weeks before or after the diagnosis of atrial fibrillation.