Overview. Consider the materials presented in this webinar during your initial PCMH planning sessions

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2 Overview NCQA PCMH 2014 Standards Strategy to create a PCMH work plan Quality improvement planning A word about renewals Summary Consider the materials presented in this webinar during your initial PCMH planning sessions ** Links to recordings will be ed to participants following this session p. 2

3 NCQA PCMH 2014 Standards Points Standard/Element Points Standard/Element 10 PMCH 1: Patient-Centered Access 20 PCMH 4: Care Management and Support 4.5 Element A Patient-Centered Appointment Access 4 Element A Identify Patients for Care Management 3.5 Element B 24/7 Access to Clinical Advice 4 Element B Care Planning and Self-Care Support 2 Element C Electronic Access 4 Element C Medication Management 12 PMCH 2: Team-Based Care 3 Element D Use Electronic Prescribing 3 Element A Continuity 5 Element E Support Self-Care and Shared Decision Making 2.5 Element B Medical Home Responsibilities 18 PCMH 5: Care Coordination and Care Transitions 2.5 Element C Culturally and Linguistically Appropriate Services (CLAS) 6 Element A Test Tracking and Follow-Up 4 Element D The Practice Team 6 Element B Referral Tracking and Follow-Up 20 PCMH 3: Population Health Management 6 Element C Coordinate Care Transitions 3 Element A Patient Information 20 PMCH 6: Performance Measurement and Quality Improvement 4 Element B Clinical Data 3 Element A Measure Clinical Quality Performance 4 Element C Comprehensive Health Assessment 3 Element B Measure Resource Use and Care Coordination 5 Element D Use Data for Population Management 4 Element C Measure Patient/Family Experience 4 Element E Implement Evidence-Based Decision Support 4 Element D Implement Continuous Quality Improvement 3 Element E Demonstrate Continuous Quality Improvement 3 Element F Report Performance 0 Element G Use Certified EHR Technology Recognition Levels Required Points Must-Pass Elements Level points Elements marked in red font are MUST PASS Level points 6 of 6 elements are required for each level Level points Score for each Must-Pass element must be 50% p. 3

4 Building a Roadmap to Recognition Three recognition levels Level 1 35 points Level 2 60 points Level 3 85 points (Perfection) Four types of activities Things you MUST do Things you already do Things you want to do Things you can do p. 4

5 Doing vs. Documenting vs. Reporting Example #1: Patient phone calls Are you taking calls? Are you noting response time for each call? Can you run a report listing response times? Example #2: Barriers to care Are you asking patients why they don t take their meds? Are you noting their response in the chart? Can you run a report listing percent of times you did that? Example #3: Health insurance Are you asking patients if they have insurance? Are you recording patients insurance details? Can you run a report showing percent of recorded insurances? p. 5

6 The Things You MUST Do The bad news: If you can t (or won t) do, document & report at least 50% of each MUST PASS Element, you will not be recognized by NCQA as a PCMH The good news: It is not difficult for a typical practice (including small ones on paper) to do, document & report at least 50% of each MUST PASS Element Must-Pass Elements Points Standard - Element 4.5 PCMH 1 - A Patient-Centered Appointment Access 4 PCMH 2 - D The Practice Team 5 PCMH 3 - D Use Data for Population Management 4 PCMH 4 - B Care Planning and Self-Care Support 6 PCMH 5 - B Referral Tracking and Follow-Up 4 PCMH 6 - D Implement Continuous Quality Improvement 27.5 Total p. 6

7 A Closer Look at MUST PASS Elements PCMH 1A Patient-Centered Appointment Access 1. Same day appointments 2. After hours appointments 3. Alternative type encounters 4. Analyze schedules 5. Act to improve schedules PCMH 4B Care Planning and Self-Care Support 1. Preferences and functional/lifestyle goals 2. Treatment goals 3. Barriers 4. Self-management plan 5. Care plan provided to patient/caregiver PCMH 2D The Practice Team 1. Formal organizational structure 2. Regular meetings (huddles, practice staff) 3. Standing orders 4. Training 5. Involve staff in quality improvements 6. Involve patients in quality improvements PCMH 3D Use Data for Population Management 1. Outreach for preventive care 2. Outreach for vaccines 3. Outreach for chronic care 4. Outreach for patients not seen recently 5. Outreach for medications monitoring PCMH 5B Referral Tracking and Follow-Up 1. Tracking to completion 2. Co-management agreements 3. Integrated behavioral health 4. Monitor self referrals 5. Evaluate specialists performance 6. Electronic summary exchange PCMH 6D Continuous Quality Improvement 1. Analyze, set goals and act to improve 2. 3 clinical quality measures 3. 1 cost/utilization measure 4. 1 patient experience measure 5. 1 disparity for vulnerable patients p. 7

8 The Things You Already Do Is there a doctor in the house? If you practice medicine in traditional primary care settings, you are providing continuity of care and evidence-based care. Documentation is simple. Are you a meaningful user? If you use a meaningful use certified EHR, even if you did not formally apply for incentives, chances are good that ONE meaningful use report will satisfy most electronic Elements (and some additional Factors as well). Points Standard/Element Points Standard/Element 10 PMCH 1: Patient-Centered Access 20 PCMH 4: Care Management and Support 4.5 Element A Patient-Centered Appointment Access 4 Element A Identify Patients for Care Management 3.5 Element B 24/7 Access to Clinical Advice 4 Element B Care Planning and Self-Care Support 2 Element C Electronic Access 4 Element C Medication Management 12 PMCH 2: Team-Based Care 3 Element D Use Electronic Prescribing 3 Element A Continuity 5 Element E Support Self-Care and Shared Decision Making 2.5 Element B Medical Home Responsibilities 18 PCMH 5: Care Coordination and Care Transitions 2.5 Element C Culturally and Linguistically Appropriate Services (CLAS) 6 Element A Test Tracking and Follow-Up 4 Element D The Practice Team 6 Element B Referral Tracking and Follow-Up 20 PCMH 3: Population Health Management 6 Element C Coordinate Care Transitions 3 Element A Patient Information 20 PMCH 6: Performance Measurement and Quality Improvement 4 Element B Clinical Data 3 Element A Measure Clinical Quality Performance 4 Element C Comprehensive Health Assessment 3 Element B Measure Resource Use and Care Coordination 5 Element D Use Data for Population Management 4 Element C Measure Patient/Family Experience 4 Element E Implement Evidence-Based Decision Support 4 Element D Implement Continuous Quality Improvement 3 Element E Demonstrate Continuous Quality Improvement 3 Element F Report Performance Marked in green font 0 Element G Use Certified EHR Technology p. 8

9 The Things You Want To Do Would you like to have a fuller schedule? Perhaps less no-show appointments? Do you have a good way to train new staff? Are there ways to get a couple more minutes with patients? How s your public image stacking up? PQRS will be made public Patient experience ratings Are you leaving money on the table? Medicare Transition of Care Management fees Medicare Chronic Care Management fees Commercial Performance bonuses, shared savings Commercial Contract negotiations Could you use credits for MOC (FM only)? Points Standard/Element Points Standard/Element 10 PMCH 1: Patient-Centered Access 20 PCMH 4: Care Management and Support 4.5 Element A Patient-Centered Appointment Access 4 Element A Identify Patients for Care Management 3.5 Element B 24/7 Access to Clinical Advice 4 Element B Care Planning and Self-Care Support 2 Element C Electronic Access 4 Element C Medication Management 12 PMCH 2: Team-Based Care 3 Element D Use Electronic Prescribing 3 Element A Continuity 5 Element E Support Self-Care and Shared Decision Making 2.5 Element B Medical Home Responsibilities 18 PCMH 5: Care Coordination and Care Transitions 2.5 Element C Culturally and Linguistically Appropriate Services (CLAS) 6 Element A Test Tracking and Follow-Up 4 Element D The Practice Team 6 Element B Referral Tracking and Follow-Up 20 PCMH 3: Population Health Management 6 Element C Coordinate Care Transitions 3 Element A Patient Information 20 PMCH 6: Performance Measurement and Quality Improvement 4 Element B Clinical Data 3 Element A Measure Clinical Quality Performance 4 Element C Comprehensive Health Assessment 3 Element B Measure Resource Use and Care Coordination 5 Element D Use Data for Population Management 4 Element C Measure Patient/Family Experience 4 Element E Implement Evidence-Based Decision Support 4 Element D Implement Continuous Quality Improvement 3 Element E Demonstrate Continuous Quality Improvement 3 Element F Report Performance Highlighted in dark grey 0 Element G Use Certified EHR Technology p. 9

10 Example: Phone Calls & Appointments p. 10

11 Example: Tools to Analyze Phone Calls p. 11

12 Example: Tools to Analyze Schedules p. 12

13 Example: Tools to Analyze Schedules p. 13

14 The Things You Can Do Also known as low hanging fruit Elements that require little effort and relatively simple documentation Points Standard/Element Points Standard/Element 10 PMCH 1: Patient-Centered Access 20 PCMH 4: Care Management and Support 4.5 Element A Patient-Centered Appointment Access 4 Element A Identify Patients for Care Management 3.5 Element B 24/7 Access to Clinical Advice 4 Element B Care Planning and Self-Care Support 2 Element C Electronic Access 4 Element C Medication Management 12 PMCH 2: Team-Based Care 3 Element D Use Electronic Prescribing 3 Element A Continuity 5 Element E Support Self-Care and Shared Decision Making 2.5 Element B Medical Home Responsibilities 18 PCMH 5: Care Coordination and Care Transitions 2.5 Element C Culturally and Linguistically Appropriate Services 6 Element A Test Tracking and Follow-Up 4 Element D The Practice Team 6 Element B Referral Tracking and Follow-Up 20 PCMH 3: Population Health Management 6 Element C Coordinate Care Transitions 3 Element A Patient Information 20 PMCH 6: Performance Measurement and Quality Improvement 4 Element B Clinical Data 3 Element A Measure Clinical Quality Performance 4 Element C Comprehensive Health Assessment 3 Element B Measure Resource Use and Care Coordination 5 Element D Use Data for Population Management 4 Element C Measure Patient/Family Experience 4 Element E Implement Evidence-Based Decision Support 4 Element D Implement Continuous Quality Improvement 3 Element E Demonstrate Continuous Quality Improvement 3 Element F Report Performance Marked in blue font 0 Element G Use Certified EHR Technology p. 14

15 Where are we on the roadmap? Must-Pass + Meaningful Use + Low Hanging Fruit = PCMH Level 2 (~65 points) To achieve PCMH Level 3 recognition you MUST measure and act to improve quality metrics p. 15

16 Strategies for Quality Improvement You can take the Elements in order and pick ad-hoc measures as you go You can select lists and reports based on what your EHR can produce You can select reports and results based on your current quality initiatives You can select measures based on performance bonuses from insurers You can combine everything into an overall strategic plan for your practice Points Standard/Element Points Standard/Element 10 PMCH 1: Patient-Centered Access 20 PCMH 4: Care Management and Support 4.5 Element A Patient-Centered Appointment Access 4 Element A Identify Patients for Care Management 3.5 Element B 24/7 Access to Clinical Advice 4 Element B Care Planning and Self-Care Support 2 Element C Electronic Access 4 Element C Medication Management 12 PMCH 2: Team-Based Care 3 Element D Use Electronic Prescribing 3 Element A Continuity 5 Element E Support Self-Care and Shared Decision Making 2.5 Element B Medical Home Responsibilities 18 PCMH 5: Care Coordination and Care Transitions 2.5 Element C Culturally and Linguistically Appropriate Services 6 Element A Test Tracking and Follow-Up 4 Element D The Practice Team 6 Element B Referral Tracking and Follow-Up 20 PCMH 3: Population Health Management 6 Element C Coordinate Care Transitions 3 Element A Patient Information 20 PMCH 6: Performance Measurement and Quality Improvement 4 Element B Clinical Data 3 Element A Measure Clinical Quality Performance 4 Element C Comprehensive Health Assessment 3 Element B Measure Resource Use and Care Coordination 5 Element D Use Data for Population Management 4 Element C Measure Patient/Family Experience 4 Element E Implement Evidence-Based Decision Support 4 Element D Implement Continuous Quality Improvement 3 Element E Demonstrate Continuous Quality Improvement 3 Element F Report Performance Quality related Elements 0 Element G Use Certified EHR Technology p. 16

17 Planned Quality Improvement 4A Select Conditions 6A, 6B Select Quality Measures 3E Select Guidelines 3C, 4B, 4C, 4E, Manage Care 3D Outreach for Services 2D Train Team Members 6D, 6E Act and Improve Quality p. 17

18 Focused Quality Example: Diabetes Care 4A Select Conditions 1 6A, 6B Quality Measures 4 1. Depression 2. LT/ST DM Complications Admit 3. Low SES 4. Uncontrolled DM 5. Plan referrals (care gaps) 3E Guidelines 1. Depression 2. Diabetes 3. UTI 4. Obesity 5. Annual visits 6. Generics - DM & Depression 2D Train Team Members 1. Diabetes standing orders 2. DM population management 3. DM self-care education 4. Diet & exercise education 5. DM QI activities 2 3 3C, 4B, 4C, 4E Manage Care 1. Pneumovax & flu shots 2. DM & Obesity screening 3. DM composite (5 services*) 4. Ophthalmology referrals 5. LT/ST complications admit 6. Stratify by SES 3D Outreach 1. Diabetes & Obesity screening 2. Pneumovax & flu shots 3. DM composite (5 services) 4. A1c > 8 & not recently seen 5. Insulin for low SES 6D, 6E Act and Improve Quality 5 6 * Comprehensive Diabetes Care Composite 5 services: (HbA1c testing, LDL C screening, BP measure, neuropathy attention: urine or ACE/ARB or referral, eye exam ) p. 18

19 A Word About Renewals Only 11 Elements require full documentation to be submitted 16 Elements require attestation only, but you MUST be able to produce proper documentation if requested (audited) by NCQA + Element PCMH 2D PCMH 6A PCMH 6B PCMH 6C Renewal Requirement At least two Factors met annually All Factors met annually Only Factor #2 met annually All Factors met annually Points Standard/Element Points Standard/Element 10 PMCH 1: Patient-Centered Access 20 PCMH 4: Care Management and Support 4.5 Element A Patient-Centered Appointment Access 4 Element A Identify Patients for Care Management 3.5 Element B 24/7 Access to Clinical Advice 4 Element B Care Planning and Self-Care Support 2 Element C Electronic Access 4 Element C Medication Management 12 PMCH 2: Team-Based Care 3 Element D Use Electronic Prescribing 3 Element A Continuity 5 Element E Support Self-Care and Shared Decision Making 2.5 Element B Medical Home Responsibilities 18 PCMH 5: Care Coordination and Care Transitions 2.5 Element C Culturally and Linguistically Appropriate Services (CLAS) 6 Element A Test Tracking and Follow-Up 4 Element D The Practice Team 6 Element B Referral Tracking and Follow-Up 20 PCMH 3: Population Health Management 6 Element C Coordinate Care Transitions 3 Element A Patient Information 20 PMCH 6: Performance Measurement and Quality Improvement 4 Element B Clinical Data 3 Element A Measure Clinical Quality Performance 4 Element C Comprehensive Health Assessment 3 Element B Measure Resource Use and Care Coordination 5 Element D Use Data for Population Management 4 Element C Measure Patient/Family Experience 4 Element E Implement Evidence-Based Decision Support 4 Element D Implement Continuous Quality Improvement 3 Element E Demonstrate Continuous Quality Improvement 3 Element F Report Performance Require documentation 0 Element G Use Certified EHR Technology p. 19

20 Where to go from here? Research Your Options Study the PCMH Standards and Guidelines BizMed is a safe and free sandbox to do just that Understand your performance bonuses (HEDIS, Star, PCMH, State, PQRS, custom) Consider using the PCMH framework for quality/business improvements even without formal recognition Objectively assess your practice and the effort required from your practice to achieve your goals DO NOT mindlessly go through all 172 NCQA Factors answering Yes/No to all questions DO NOT assume that doing something is enough without documenting, measuring and reporting DO decide on your personalized practice roadmap to PCMH recognition Make a Plan Define your goals Use these materials to draw your roadmap to achieving those goals Assign resources and understand that physicians MUST be involved Estimate time frame to completion and pick meaningful milestones to guide you Stay the course there will be good days and plenty of bad days And yes, it is worth the effort p. 20

21 PCMH PCMH A Practice Management Framework An opportunity. What are your practice goals? Financial Management Operations Management Care Management Quality Management Missing from NCQA PCMH Included in NCQA PCMH Step1: Define your goals Step 2: Refine & expand the framework to address your goals p. 21

22 Summary PCMH is just a framework p. 22

23 Contact info: Margalit Gur-Arie Mobile: For more information and assistance: On the web: Phone: ** Links to recording will be ed to participants following this session p. 23

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